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WASHINGTON, D.C. 20594
HAZARDOUS MATERIALS RELEASE
FOLLOWING THE DERAILMENT OF
BALTIMORE AND OHIO RAILROAD COMPANY
TRAIN NO. SLFR
UNITED STATES GOVERNMENT
s -Uo -flt 7/yy3
"n Report No.
TECHNICAL REPORT DOCUMENTATIOH PA^^'^'
2. Government Accession No.
4. Title and Subt i tie fiHg(zai.(jous Materials Accident
Report— Hazardous Materials Release Following the
Derailment of Baltimore and Ohio Railroad Company Train
No. SLFR. Miamisburg. Ohio. July 8. 1986
3 .Reci pient ' s Catalog No.
5. Report Date
6. Performing Organization
8. Performing Organization
9. Performing Organization Name and Address
National Transportation Safety Board
Bureau of Accident Investigation
Washington, D.C. 20594
lO.Work Unit No.
11. Contract or Grant No.
12. Sponsoring Agency Name and Address
NATIONAL TRANSPORTATION SAFETY BOARD
Washington, D. C. 20594
13. Type of Report and
July 8, 1986
l^* .Sponsor i ng Agency Code
15. Suppi ementary Notes
16. Abstract Qn July 8, 1986, 15 cars of a southbound Baltimore and Ohio Railroad Company
freight train derailed while traveling at 45 mph near Miamisburg, Ohio. Three of the 15
derailed cars were tank cars containing yellow phosphorus, molten sulfur, and tallow. While
derailing on a bridge, these tank cars were extensively damaged, lost product, and were
involved in the resulting fire. Approximately 7,000 residents from a section of Miamisburg
were initially evacuated as a safety precaution. On the following day as a
wreckage-clearing crew was preparing to remove the smoldering phosphorus tank car, a
concrete structure supporting the tank car collapsed, and several hundred gallons of molten
phosphorus inside the tank car escaped and ignited, resulting in an extensive cloud of
phosphorus combustion effluents. During the following 48 hours, a 3-square-mile area of
Montgomery County, Ohio, was evacuated, forcing an estimated 30,000 people to leave their
homes and businesses; 569 persons were treated for various complaints during the incident.
Total property damage was $3,540,000 including the cost of hazardous materials.
The National Transportation Safety Board determines that the probable cause
of the uncontrollable release of phosphorus was the failure of the unprotected bottom brake
support attachment during the derailment resulting in the tearing of the tank shell.
Contributing to the rupture of the tank was the Federal Railroad Administration's failure to
require retroactively that reinforcement pads be installed between tank shells and welded
/. ey or s tank car; fire; hazardous materials;
emergency response; derailment; phosphorus; sulfur;
tank car attachment; AAR; Tank Car Committee; FRA;
delegation of authority
(of this report)
20. Security Classification
(of this page)
l8.Di str i but ion Statement
This document is available
to the public through
the National Technical
Springfield, Virginia 22161
21 .No. of Pages
NTSB Form 1765.2 (Rev. 9/74)
EXECUTIVE SUMMARY v
The Accident 1
Hazardous Materials Release 1
Emergency Response 3
Direct Hose Stream Attack 8
Water Flooding of the Interior of the Phosphorus Tank Car 8
Apply Foa m 8
Open Manhole 9
Explosive Demolition 9
Injuries to Persons 10
Meteorological Information 10
Emergency Preparedness 11
Product Information 11
Yellow Phosphorus 11
Temk Car Information 13
UTLX 79499 13
UTLX 76486 15
UTLX 77400 16
Protection of Attachments 16
Development of Tank Car Safety Standards 20
Initial Tank Car Safety Program 20
FRA Tank Car Safety Program 21
AAR Tank Car Safety Program 24
The Canadian Transport Commission 27
Case History: FRA Oversight of AAR Tank Car Safety Activities 29
Emergency Response 36
Initial Response Actions 36
Longer-Term Actions 38
Emergency Response Guides 39
Tank Car Performance 40
Tank Car Coupler and Thermal Insulation Performance 41
Tank Car Attachment Performance 41
Tank Car Safety Programs 43
Probable Cause 47
Appendix A— Investigation 51
Appendix B— Railroad Accident/Incident Summary Report 52
Appendix C— Safety Board Recommendations For Improvement of
Hazardous Materials of Tank Car Safety 57
Appendix D— Summary of Federal Railroad Administration Delegation of
Authority to Association of American Railroads for Tank Car
Safety and Related FRA and AAR Procedures and Operations 58
Appendix E— Association of American Railroads Responses
to Selected Questions 64
Appendix F— Excerpts From Relevant Emergency Guides
For Phosphorus 73
Appendix G— Canadian Railways Transport Committee Board of Inquiry:
MacMillan Yard Accident 77
At 4:25 p.m., on July 8, 1986, 15 cars of a southbound Baltimore and Ohio Railroad
Company freight train consisting of 44 ears and a locomotive, derailed while traveling at
45 mph near Miamisburg, Ohio. Three of the 15 derailed cars were tank cars containing
yellow phosphorus, molten sulfur, and tallow. While derailing on a bridge, these tank cars
were extensively damaged, lost product, and were involved in the resulting fire.
Approximately 7,000 residents from a section of Miamisburg were initially evacuated as a
On the following day, as a wreckage-clearing crew contracted by the railroad was
preparing to remove the smoldering phosphorus tank car, a concrete structure supporting
the tank car collapsed, and several hundred gallons of molten phosphorus inside the tank
car escaped and ignited, resulting in an extensive cloud of phosphorus combustion
effluents. During the following 48 hours, a 3-square-mile area of Montgomery County,
Ohio, was evacuated, forcing an estimated 30,000 people to leave their homes and
businesses; 569 persons were treated for various complaints during the incident. Total
property damage was approximately $3,540,000, including the cost of hazardous materials
Observation of emergency response activities and the conditions that led to
hazardous materials release following the July 8, 1986, derailment in Miamisburg, Ohio,
prompted the Safety Board to conduct this hazardous materials accident investigation.
The investigation revealed that the major release of phosphorus came from a breach in
the tank shell in an area where a bottom attachment was welded directly to the tank
shell. Other tank shell failures at attachments have raised the Safety Board's concern
about the adequacy of Federal safety standards and the Federal Railroad Administration's
oversight of tank car performance. As a part of this investigation, the Safety Board
reviewed the adequacy of the Federal Railroad Administration's delegation to the
Association of American Railroads of tank car safety authority and how the FRA
monitored actions taken by the AAR under the delegated authority. The safety issues
discussed in this report are:
o effectiveness of hazardous materials emergency response activities
and guides inducing the outcome of the emergency;
o crashworthiness of hazardous materials tank cars during
o effectiveness of FRA's delegation of authority to the AAR for tank
As a result of its investigation, the Safety Board issued recommendations to improve
the accuracy and consistency of information provided in emergency response guides; to
identify and report tank car deficiencies; to determine the adequacy of tank car
specifications; and to establish procedures for determining that tank car construction and
repair comply with Federal standards. The Safety "^oard made recommendations to the
Federal Railroad Administration, the Research and Special Programs Administration of
the U.S. Department of Transportation, CSX Transportation, and the Association of
American Railroads concerning these safety issues.
The National Transportation Safety Board determines that the probable cause of the
uncontrollable release of phosphorus was the failure of the unprotected bottom brake
support attachment during the derailment resulting in the tearing of the tank shell.
Contributing to the rupture of the tank was the Federal Railroad Administration's failure
to require retroactively that reinforcement pads be installed between tank shells and
NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D. C. 20594
HAZARDOUS MATERIAI^ ACCIDENT REPORT
Adopted: September 29, 1987
HAZARDOUS MATERIALS RELEASE FOLLOWING
THE DERAILMENT OF BALTIMORE AND OHIO RAILROAD COMPANY
TRAIN NO. SLFR
JULY 8, 1986
At 4:25 p.m., on July 8, 1986, 15 cars of southbound "altimore and Ohio Railroad
Company 1/ (B&O) freight train Southland Flyer (SLFR), consisting of a locomotive and 44
cars, derailed while traveling at 45 mph on a through-plate bridge 2/ (bridge 497 at
milepost 49.7) spanning the Bear Creek at Miamisburg, Ohio. (See figure 1.) Train SLFR
was being operated with all four crewmembers in the locomotive and with an
"end-of-train" monitoring device. 3/ Three tank cars were breached and lost some or all
of their contents. Within minutes, large plumes of smoke were emitted from the
wreckage, and soon thereafter a large pool of spilled materials ignited.
The locomotive and the 1st through the 27th cars remained coupled together and
stopped 21,867 feet south of bridge 497. Four of these cars, the 24th through the 27th,
were derailed but remained upright and separated from the trailing cars by 1,531 feet.
The next 11 cars, the 28th through 38th, were derailed but remained aligned with the
track structure and stopped south of the bridge. The remaining cars stopped on the north
side of the bridge. (For more detailed information, see appendix B.)
Hazardous Materials Release
The 30th car, Union Tank Car Company (UTLX) 79499, a tank car loaded with yellow
phosphorus, came to rest on its side south of the bridge with its dome rotated to the east
approximately 45°. The tank car's 2 -inch water introduction pipe was open, the B-end
1/ At the time of the accident, the Baltimore and Ohio Railroad Company was a
subsidiary of the Chesapeake and Ohio Railway Company, and on May 1, 1987, the B&O
merged into the C&O, a wholly owned subsidiary of CSX Corporation.
2/ A bridge structure framed to allow the track to be supported at or near the bottom
flanges of the plate girder.
3/ A device that provides a red marker light at the end of a train not provided with a
caboose. Additionally, by radio telemetry the end-of-train device provides the engineer a
digital readout of the airbrake pressure at the end of the train and of any change in air
top washout nozzle along with the tank shell adjacent to the airbrake support bracket
were breached during the derailment and subsequent fire, releasing thick clouds of
phosphorus combustion effluents (see figure 2). Liquid phosphorus was released on to the
ground through the 8 -inch tear in the bottom of the tank shell at the airbrake support
bracket attachment. The exposed phosphorus smoldered and ignited within 15 minutes.
The 33rd car, UTLX 76486, a tank car loaded with molten sulfur, began releasing its
contents during the derailment just north of the bridge. This car came to rest straddling
the south headwall of the bridge and just behind the 30th car. This car received three
tank head punctures: the trailing head had a 24 -inch -long fracture and the leading head
had both a 10-inch-diameter and a 28-inch-long fracture. A large volume of molten
sulfur was released through these punctures and spilled onto the bridge and into the creek
before the phosphorus ignited.
The 34th tank car, UTLX 77400, containing tallow, came to rest on the south span of
the bridge. The leading head had a puncture approximately 12 by 6 inches directly above
the draft sill. Tallow was released into the creek through this puncture.
Immediately after the derailment, the crew observed what appeared to be a dust
cloud at the rear. The conductor reviewed the waybills to determine what "Dangerous" 4/
commodities might be involved. The waybills identified two tank cars (the 12th and 30th)
as "Dangerous" and listed their commodities as sodium hydrosulfide and yellow
phosphorus, respectively. The way bill for the phosphorus tank car (30th) also was marked
"Poison." 5/ Shortly thereafter, the conductor and the front brakeman left the locomotive
and began walking north along the forward portion of the train. While a crewmember
could have approached from the rear safely, no one was sent to the rear of the train to
determine which of those rail cars remained upright. Almost concurrently, about
4:29 p.m., a nearby resident telephoned the Miamisburg police/fire dispatcher, and fire
and police units were immediately dispatched. A city fire inspector, who was on the
Sycamore Street Bridge near the accident site saw smoke coming from the derailed cars
at 4:30 p.m.
Shortly after 4:31 p.m., the first arriving local emergency personnel approached
within 100 feet of the southwest side of the bridge. These first responders, a policeman
and firefighter, reported that because of the thick smoke they could only see two tank
cars (the 30th and 33rd) just south of the bridge. They saw the bottom of the 30th car
facing west with a tear in its shell; they could not see the condition of the 33rd car.
Placards were no longer in place on the ends and sides of the 30th car because they had
been torn off during the derailment. Thus, the emergency responders were not alerted
that the hazardous materials were involved in the derailment nor did they realize the need
to wear personal protective equipment. They reported that "there was a small
yellowish-white fire visible within the bottom of the one tank car [30th] and that a large
cloud of very thick white smoke was billowing from the hole."
When the conductor and front brakeman proceeded past the fourth car north of the
locomotive, they saw billowing white smoke and cars on the ground south of the bridge.
The conductor said that because he knew that two ears in the train contained hazardous
4/ Title 49 CFR Section 174.25 requires "Dangerous" to be noted next to the car number
on waybills, switching orders, and other billing for most classes of hazardous materials.
5/ Denotes the Canadian subsidiary classification for phosphorus.
materials, he contacted the B&O Dayton dispatcher using his portable radio, reported the
train's location, and requested local emergency assistance. At this time the conductor was
unable to determine if either of the hazardous materials tank cars were involved in the
derailment. At 4:37 p.m., the B&O Dayton dispatcher contacted the Miamisburg Police
Department reporting "a train derailment on the Chessie System 6/ and west of the Miami
River and south of Sycamore Street.
The conductor and the front brakeman continued to walk along the forward portion
of the train passing the first "Dangerous" tank car (12th). When they reached the 27th
car, the northernmost standing car in the forward portion of the train, the conductor
obtained the car number and, referrir^ to the train profile, assumed that the other
remaining "Dangerous" tank car (30th) was involved in the derailment. During this time
the car numbers of the standing cars were radioed to the dispatcher as the conductor
walked toward the south end of the bridge to get additional car information.
Shortly afterward, the conductor approached south of the bridge and met the
emergency responders. The conductor advised the emergency responders that "the car on
fire was filled with yellow phosphorus which is a poison," and further added that the
immediate area should be evacuated. At this time, the intense smoke and heat prevented
identification of other cars south of the bridge. The conductor advised that he had the
train profile, and the responders requested that he accompany them to the command post.
Before leaving with the conductor, the responders noted that within the few minutes they
had been observing the accident, the fire in the 30th ear had grown and was spilling out of
the tank car from a hole in the tank bottom creating an extensive cloud of smoke which
was drifting east over Miamisburg.
While en route to the scene, the firechief of the Miamisburg Fire Department was
advised that the conductor had identified the burning material from the tank car as
phosphorus. The firechief ordered an immediate evacuation of the west side of the Great
Miami River. Later, after seeing the direction and size of the cloud, he ordered an
evacuation of the northeast section of Miamisburg, approximately 1/3 of the city.
A command post was established approximately 1/4-mile south of the Bear Creek
Bridge (on Sycamore Street). At the command post, the conductor provided the firechief
preliminary information from the train profile on the materials being transported. The
fire department, because of training previously provided by the B&O, expected more
information than the conductor provided and requested all information that was carried on
the train. The conductor returned to the locomotive, collected the scattered waybills
that had fallen to the floor of the locomotive during the derailment, and returned to the
command post with the waybills. A "Canadian Emergency Response Form for Special
Commodity PHOSPHORUS" 7/ (see appendix F) that included the shipper's 24-hour
emergency telephone number, was not among the waybills provided to the firechief at the
command post. Because the train's crewmembers had not determined the status of the
cars at the rear of the train, the conductor was unable to provide accurate information on
the cars involved in the derailment or on the materials contained in the derailed cars. To
6/ The Chesapeake and Ohio Railway Company.
7/ On shipments originating in Canada, Canadian law prescribes a specific form of
emergency response documentation to accompany the waybills for hazardous materials
moving by rail. According to a representative of CSX, the CSX/Association of American
Railroads (AAR) emergency guidance for phosphorus was not made a part of the papers
carried on this train to avoid any confusion that might result from having both the
Canadian and the CSX/AAR emergency guidance for phosphorus.
obtain the necessary information, firefighters, in full protective equipment, entered the
derailment site to document the derailed cars and obtain the numbers of the cars
immediately to the south and north of the bridge.
During this time, the B&O assistant chief dispatcher contacted the trainmaster who,
having overheard the radio conversation between the conductor and the B&O Dayton
dispatcher, was already en route to the site. When the trainmaster arrived at 5 p.m., he
observed the general derailment area and the "spilled materials flowing into the Bear
Creek." The trainmaster went to the command post and assisted the conductor in his
review of the train profile and waybills to confirm the dangerous commodities that might
have been involved in the derailment. Following this review, the conductor advised the
firechief that the tank cars involved in the derailment contained phosphorus, sulfur, and
After reviewing the train consist and waybills with the public safety officials, the
trainmaster contacted his dispatcher to notify appropriate subcontractors for wreckage
clearing and chemical cleanup. Additionally, the trainmaster had his dispatcher contact
the Chemical Transportation Emergency Response Center (CHEMTREC) 8/ and obtain
guidance for handling phosphorus. According to the trainmaster, he met with the
firechief around 6 p.m. and based on information obtained from CHEMTREC, he advised
the firechief "not to use water to fight the fire since they could not flood the phosphorus
with water and spraying would not put it out." Additionally, the trainmaster stated that
he advised the firechief that B&O intended to begin removing the rail cars to permit
access to the site. According to the firechief, he did not have this conversation with the
Among the hazardous materials emergency response guidelines available to the
firechief on scene were the 1980 and 1984 editions of the U.S. Department of
Transportation (DOT) Emergency Guide for Hazardous Materials (DOT guide) and the
National Fire Protection Association's (NFPA) "Hazardous Chemicals Data." (See
appendix F.) Guide No. 38 of the 1980 DOT guide advised isolating the hazardous area,
denying entry, and flooding the area with water to cool the containers exposed to flames.
It also advised wearing self-contained breathing apparatus and full protective
clothing. 9/ Guide No. 49 of the NFPA guide indicated that when a mixture of sulfur and
yellow phosphorus is warmed, the two elements unite with vivid combustion and a
powerful explosion. The NFPA guide also advised deluging with water, taking care not to
scatter the fire, until it is extinguished and the phosphorus has solidified. Further, this
guide advised that it then should be covered with water.
Various fire units and representatives from State agencies began arriving on scene
during the evacuation. The firechief consulted with other firechiefs who had responded to
the site to obtain their recommendations on what emergency response tactics should be
used. Assisting the Miamisburg Fire Department were 14 fire departments from nearby
8/ The Chemical Transportation Emergency Center of the Chemical Manufacturers
Association maintains a 24 -hour hotline for emergency information and shipper contacts
for hazardous material transportation emergencies.
9/ Since 1980 the DOT has made significant changes to the 1980 guide which are
reflected in the 1984 DOT Guide. The 1984 DOT guide advises among other things to
isolate the hazard area and deny entry, to use water spray or fog for large phosphorus
fires, to not scatter material with more water than is needed for fire control, and to use
water spray to reduce vapors.
eommunities and a regional hazardous materials response team. Additionally, the
Director of the Miami Valley Disaster Services Authority (MVDSA) assisted in establishing
communications and coordinated the activities of the responders.
The firechief wanted to keep all personnel, including railroad personnel, out of the
fire area until the fire was under control. The firechief considered the firefighting
tactics suggested by the other firechiefs. Because of limited access to the site and
because water cannons with direct hose streams were the only available apparatus capable
of reaching the burning cars, the firechief said that he had no choice at the time but to
fight the fire at a distance using direct hose streams. The trainmaster challenged the
authority of the city and the firechief to handle the emergency; he was escorted from the
command post under threat of arrest.
Fire engines were moved into position to draft water from Bear Creek and the Great
Miami River. About 7:10 p.m., the attack began and approximately 3,500 gallons of water
per minute were flowing on to the fire. Because of the DOT guidance that said to avoid
the acid fumes, 15-person crews rotated shifted at the four water cannons that deluged
the phosphorus tank and spill area. Because of the intense fire and the warnings about the
possibility of an explosion and the formation of a highly toxic gas if the spilled phosphorus
and sulfur reacted, 10^/ the firechief ordered all other personnel out of the area. During
this operation, additional unknown amounts of phosphorus, sulfur, and tallow were carried
into the creek by the water used to deluge the tank cars. Later, to minimize the release
of pollutant runoff from the hose streams into the Great Miami River, a containment
boom was placed across the Bear Creek.
While the fire department worked to extinguish the flames, other local agencies
coordinated the evacuation of sections of Miamisburg, West Carrollton, and Moraine.
When the previously initiated evacuation was completed, an estimated 7,000 persons,
mostly from the residential district north of Central Avenue in Miamisburg, were
Around 8 p.m. the fire from the phosphorus tank car was no longer apparent, but
smoke and flareups continued in the immediate area at the south end of the bridge;
commodities on other derailed cars were still burning out of reach of hose streams being
used at that time. By 8:26 p.m. smoke was no longer emitting from the phosphorus tank
car. With the fire under relative control, the firechief allowed B&O personnel to begin
removing the standing cars on the north side of the bridge. While Safety Board
investigators could not determine the specific details of the conversation between the
firechief and B&O officials, the firechief later said that the believed that B&O had
advised that "the sulfur tank car was still on the tracks on the north side of the bridge and
an engine was sent down [from Moraine] to transport the sulfur tank car to Dayton." 11/
Later in the evening, emergency specialists representing the shipper, the carrier,
subcontractors, and State and Federal agencies arrived in Miamisburg. The firechief met
with these representatives and used the information they provided over the next several
days to make decisions during the emergency.
10 / The NFPA guide warned about the possibility of an explosion, while a local chemist
warned about the possibility of an explosion and/or the possible formation of a deadly gas,
11 / Actually there was an empty tank ear, the 43rd car, which was on the north side of
the bridge and at the rear of the train.
Shortly after midnight, a B&O evaluation team was allowed to enter the fire scene
to assess the extent of damage to the phosphorus tank car (30th) and to determine the
amount of phosphorus remaining. During these operations, the B&O confirmed that the
sulfur car (33rd), in fact, was on the bridge. This information was provided to the
firechief about midnight during an organizational meeting called by the firechief. The
evaluation team determined that there appeared to be two holes on the top and an 8 -inch
hole in the bottom of the phosphorus tank car (30th); they estimated about 4,000 gallons
of product remained inside the burning car.
During the first and second day of the emergency, several proposals for handling the
emergency relative to the phosphorus tank car were evaluated during meetings at the
Direct Hose Stream Attack. — The B&O and later, on the second day, the Ohio
Environmental Protection Agency (EPA) recommended that since the fire from the
phosphorus had abated, the direct hose streams should be shut off and a mist be used to
control the smoke from the tank car. After several attempts to remove the firehoses
briefly, the tank car fire began to rebuild in intensity. Additionally, the B&O advised that
the phosphorus tank car was perched on an embankment that was being eroded by the
heavy discharge of water. The firechief was aware that a second flareup was possible if
the tank car moved, but B&O specialists advised him that the tank car likely would not
move. The firechief said that he was unable to move misting apparatus close enough to
the tank car to apply a water mist. For this reason, the firechief could not comply with
the recommendation, and he ordered continued use of the hose streams to deluge the
phosphorus tank car, but he reduced the rate of water flow during the first night.
Plugging. — The B&O initially believed that if the holes in the phosphorus tank car
could be plugged, the fire could be extinguished. However, this tactic was not feasible
mainly because of the large bottom hole in the tanks shell.
Water Flooding of the Interior of the Phosphorus Tank Car. — The B&O believed that
if the tank car was repositioned so that the bottom hole was well above the liquid level, a
blanket of water could be injected and possibly smother the fire or seal the remaining
phosphorus inside the tank car. However, after several attempts to add water, response
personnel saw liquid phosphorus flowing from the top washout nozzle and small shell holes
causing the fire to intensify.
Apply Foam. — Tank car specialists recommended that to exclude air from the
phosphorus tank car, the car should be covered with a new and improved foam. This plan
was never attempted because the fire in the tank car intensified before the foam arrived.
Burial. — Burial was tentatively discussed as an alternate approach should the other
methods fail. However, this plan could not be attempted until the fire subsided because
to exclude air from the phosphorus tank car, it would have to be moved to a deep pit
excavation and covered with sand.
On July 9, 800 residents were still prohibited from returning to their homes in the
immediate area of the derailment. At 6:05 p.m. a concrete structure, 12/ not a part of
the bridge, that had been supporting the phosphorus tank car sank approximately 1.5 feet
due to erosion caused by the large volume of water directed on to the car. As a result,
12/ The concrete structure was identified by CSX as a preexisting structure whose
purpose is unknown.
the tank car tilted about 15° to the north and a large amount of molten phosphorus inside
the tank car shifted and apparently escaped through the hole in the washout. The fire
intensified and released a thick, massive smoke plume. The firechief decided that the fire
was beyond control; thus, the hose streams were directed onto the tank car to cool the
metal to prevent a massive breakup and thus intensity the fire.
As winds shifted, the large smoke plume was carried east at 6 mph over Miamisburg.
Later in the evening on July 9 as the wind subsided, a weather inversion developed causing
the cloud to remain close to the ground. The city and surrounding jurisdictions initiated a
second major evacuation affecting an estimated 30,000 persons. 13^/ The evacuated areas
included Miamisburg, West Carrollton, Moraine, Miami Township, and parts of Washington
Township. Police departments from 53 jurisdictions assisted in the evacuation of the city
and surrounding areas; 12 shelters were opened near Dayton, Ohio.
On July 10, with the prevailing winds at 5 to 10 mph from the south at 135°, the
plume was fairly dense and low to the ground. An environmental monitoring station
1 mile northwest of the tank car measured 5.0 mg/m3 of phosphorus aerosol which
exceeded the threshold limit of 0.1 mg/m3. 14/
During meetings at the command post on July 10, proposals were discussed to
dispose of the estimated 1,000 gallons of phosphorus remaining in the tank car.
Open Manhole. — It was estimated that if air was blown directly into the tank car,
the burn rate of the phosphorus would accelerate and consume the remaining 1,000 gallons
in about 12 hours. To accomplish this, the manhole cover bolts would have to be removed
by cutting, an air blower would have to be put in position, and a 6 -inch fan duct would
have to be inserted through the manhole to enhance the burn rate.
Explosive Demolition. — The EPA proposed that explosive demolition be used to blow
a hole in the car to accelerate the burn rate It believed that this method would be safer
than opening the manhole.
The firechief, in consultation with the city manager, decided to proceed with the
accelerated burning through the opened manhole because he believed it to be a more
controllable process. The rate of interior burning increased when the liquid surface was
exposed to the increased volume of air. On July 11 the intensity of the fire was reduced
sufficiently and the phosphorus tank car was moved 35 feet to a level position. After
24 hours, the rate of burning decreased sufficiently to allow further inspection of the tank
car. It was found that 4 inches of phosphorus residue was "crackling and bubbling" in the
bottom of the tank car. Water was poured over the remaining phosphorus to extinguish
the fire. The car was then pulled 60 feet to a bed of sand where it was cut open. The
remaining product was loaded into drums for disposal. The evacuation order was lifted on
July 12, 5 days following the derailment.
To minimize environmental pollution, the area of Bear Creek between the bridge
and the Great Miami River was isolated by a barrier dam from July 9 through July 11 and
diverted to the north around an area adjacent to the derailment. Approximately
200,000 gallons of water per day were treated for several weeks with hydrogen peroxide
13/ This was reportedly the most extensive evacuation in the United States following a
hazardous materials railroad accident.
14 / The threshold limit is the time-weighted average concentration for a normal 8-hour
workday and a 40 -hour workweek, to which nearly all workers may be repeatedly exposed
day after day without adverse effects.
to neutralize the phosphorus. The water was then filtered through a sandbed before being
discharged to the municipal sewage treatment facility. In addition to water treatment,
the contaminated soils from the creekbed and railbed were excavated to a depth of 12 to
13 feet. The contaminated soils were placed on an asphalt pad to aerate and mix with
hydrogen peroxide. After the soils were treated, they were disposed of at a landfill.
Approximately 5,000 cubic yards of contaminated soil were removed over 2 months.
Injuries to Persons
Crew members Personnel Others Total
Local hospitals received 569 patient visits 15/ including 27 patients who were
hospitalized with complaints relating to the spill; specifically, shortness of breath, burning
eyes, and throat irritation. Ten emergency responders were treated for heat exhaustion
and inhalation complaints. One firefighter received phosphorus burns on his leg, and two
others received minor ankle and head injuries.
Damage was estimated by CSX as follows:
Track $ 10,000
Bridge str uc ture 175,000
Rail equipment 242 , 000
Civilian response 480,000
Environmental cleanup 2,000,000
This loss estimate does not include costs to evacuees, community disruption, or business
The following average weather conditions were observed at the J.M. Cox
International Airport, Dayton, Ohio, 18 miles from Miamisburg, Ohio. From 3 p.m. until
8 p.m. on July 8, 1986, the sky was scattered to overcast with 5 to 6 mile visibility with
thunderstorms and light rain (.6 inches); the average temperature was 87° F, dewpoint was
71° F, and the wind was from the southwest at 11 knots.
On July 9, the wind shifted from the southwest to northwest at 7 to 10 knots; there
was haze with fog in the evening, and the sky was overcast. From July 10 through
July 12, the wind was mostly from the southeast with periods of rain showers and the
temperature was in the 70s.
15/ Ohio Department of Health Report— "Miamisburg Hazardous Material Incident:
Emergency Room Study," (860726), June 29, 1987.
On April 14, 1986, the B6cO conducted a training session with the Miamisburg Fire
Department covering B&O procedures for obtaining hazardous materials assistance and
covering information the traincrew will provide in the event of a derailment. Also, the
B6cO conducted similar sessions with other fire departments in the area during this time.
In large part, initial training was provided from programs sponsored by local
industries, the railroads, and other organizations. This training, which totaled 20 hours,
included identifying hazardous materials, recognizing and dealing with explosives, dealing
with railroad emergencies, and introducing the trainees to specialized hazardous materials
equipment. The sources of this training were the Dayton Police Department Bomb Squad,
the Ohio State Fire Marshal's Office, the Chessie System, the Detroit, Toledo and Ironton
Railroads, and an NFPA-DOT slide program.
During April 1982, six members of the response teams, members of the Dayton Fire
Department, Huber Heights Fire Department, Kettering Fire Department, and the
Washington Township Fire Department were sent to the Colorado Training Institute for
Hazardous Materials to attend an 80-hour in-depth and hands-on program. After they
returned from the school, the MVDSA prepared a comprehensive training program for the
other members of the response team; the program was prepared and conducted through
the end of August 1982. This phase of training totaled some 50 hours of both classroom
and practical instruction. It covered the following areas: a refresher course on the proper
procedures for identifying hazardous materials; chemical properties of hazardous
materials; specialized equipment use and maintenance; containment procedures i.e.,
plugging, patching, diking, etc.; hazardous material tactical considerations; evacuation
procedures; and decontamination procedures. The MVDSA conducts about 20 exercises a
year. In August 1984 MVDSA conducted a full-scale exercise involving over 20,000
Yellow Phosphorus. — Yellow phosphorus appears as a pale yellow waxy solid at room
temperature with a sharp pungent odor resembling garlic. Yellow phosphorus does not
react with water and is stable as long as it is kept submerged or otherwise excluded from
air. On exposure to air, phosphorus will begin to heat and smolder, and on reaching 86° F,
it ignites. Consequently, phosphorus is transported in insulated tank cars in molten form
for ease of unloading and under a thick layer of water to prevent exposure to air. Burning
phosphorus produces irritating and toxic combustion products, which may include
orthophosphoric acid fumes and phosphorus pentoxide, both are hazardous materials
classified as corrosive. Under U.S. hazardous materials regulation, yellow phosphorus is
classified as a "flammable solid;" 16/ under Canadian regulations, yellow phosphorus is
classified as "spontaneously combustible."
On June 23, 1986, Tenneco Canada, Inc., (ERCO Industries, Ltd.) loaded UTLX 79499
at Varennes, Quebec, with 176,798 pounds (approximately 12,000 gallons) of yellow
phosphorus at approximately 130° F and covered it with 25 inches of water. When the
tank car was shipped on June 27, 1986, ERCO furnished the Canadian National Railways a
certified bill of lading, the required Canadian Emergency Response Form, Plan
16/ Under 49 CFR 173.150, a "flammable solid" is any solid material, other than one
classified as an explosive, which can be ignited readily and when ignited, burns so
vigorously and persistently as to create a serious transportation hazard. Included in this
class are spontaneously combustible materials.
No. ERP2-001 (see appendix F), and ERCO's emergency phone number. The Canadian
National Railways prepared the waybill to accompany this shipment to its destination at
Albright and Wilson, Inc., in Fernald, Ohio. The waybill described the shipment as
"Phosphorus, white or yellow, in water, spontaneously combustible 4.2(6. 1)(9. 2) 17/
UN1381 Package Group I RQ." The Canadian National Railways added to the waybill the
required "Dangerous" placard endorsement (as stipulated under 49 CFR Sections 174.25,
and 174.83 through 174.93) along with the "Poison" endorsement which indicated that
special handling was required, and assigned Standard Transportation Commodity code
(STCC) 4916141 18/ to the shipment. The crewmembers of train SLFR were provided, in
addition to the waybill, the Emergency Response Plan No. ERP2-001.
CSX stated that at the time of the Miamisburg derailment, the normal CSX practice
was to enclose a document entitled "Emergency Handling Precautions" for that particular
commodity and the waybill covering and accompanying a shipment of certain hazardous
substances. (See appendix F.) This document describes the basic characteristics of a
substance and emergency measures for handling spills, fires, etc. The same information is
maintained within the CSX computerized data system and can be accessed via terminals
located in CSX offices throughout the railroad includir^ those of dispatchers. The
document is generally placed with the waybill at the time the bill is prepared or when the
waybill is received with the car in interchange from another carrier. However, when the
CSX receives a Canadian-origin car, the Canadian Emergency Response Form or Plan for
the particular commodity is retained with the waybill in lieu of adding CSX's emergency
handling precautions form. This practice is followed in order to avoid possible confusion
that may occur by having two sets of guides covering the same equipment.
Sulfur. — Molten sulfur is sulfur that has been maintained above 245° F and can
present toxic hazards either due to the release of entrained hydrogen sulfide, a toxic
flammable gas, or due to the release of sulfur dioxide, a product of combustion. Sulfur is
not regulated for rail transport and does not require the identification of the hazard class
and packaging in transportation under 49 CFR Part 172.
Marathon Oil loaded UTLX 76486 with 197,840 pounds or approximately
13,000 gallons of molten sulfur, and the tank car was shipped on July 2, 1986, from
Detroit, Michigan, en route to Dupont, at Fort Miami, Ohio.
The Safety Board previously has directed the DOT's attention to the necessity for
classifying and regulating sulfur and other molten materials. Based on its findings on the
hazards of molten sulfur as a result of its investigation of a January 19, 1985, highway
accident at Benicia, California, the Safety Board recommended the DOT's Research and
Special Programs Administration (RSPA):
Regulate molten sulfur and, as appropriate, other molten materials as
hazardous materials, prescribe packaging and handling standards, and
incorporate information relating to the hazards of these materials into
warning devices and publications available to emergency responders and
others involved in the transportation of molten materials.
17/ Under the Canadian hazard classification system the primary (4.2) as well as the
subsidiary classification (6.1 and 9.20) are required on the waybill; i.e., primary hazard is
"spontaneously combustible," and subsidiary hazards, are "toxic" and "hazardous to the
18/ STCC numbers are seven-digit numbers identifying a specific hazardous materials as
indexed in the STCC of Hazardous Materials of the AAR.
Classify as priority action the proposed rulemaking in Docket HM-178
regarding the definition of flammable solid, and establish a timetable for
its completion. Include in the final rule test requirements and clear,
objective criteria for shippers to identify those materials included in this
RSPA concurred in the Safety Board's assessment that molten sulfur should be
regulated, and on November 21, 1986, it published a rulemaking (Docket HM-198)
proposing to regulate as hazardous materials sulfur and other molten materials.
Additionally, on May 5, 1987, under separate rulemaking (Docket HM-181— comments due
November 2, 1987) RSPA is proposing the adoption of the United Nations classification for
sulfur as "spontaneously combustible." Under Docket HM-198 rulemaking actions, RSPA
sought information on other molten materials that potentially posed hazards sufficient for
the DOT'S regulation and sought comments relative to the extent such materials should be
regulated. The Safety Board responded to the HM-198 rulemaking proposal by providing
information on additional accidents where nonregulated molten materials posed hazards,
and advised the DOT that in assessing the need to regulate molten materials, the DOT
should consider the hazards posed by these materials within the various transportation
environments. For rail transportation, the Safety Board advised that the hazards
presented by the potential chemical interaction between sulfur and other materials also
should be evaluated, and it urged the DOT to match the probable consequences of a
molten material accident with the necessary safeguards.
Tank Car Information
UTLX 79499. — This tank car was a 12,500 -gallon, DOT specification 103 W tank car
built by UTLX in June 1966. It was specifically designed to transport phosphorus. The car
was equipped with 100 -ton trucks, type E top- and bottom-shelf couplers, and exterior
heater coils. It was insulated with 4 inches of fiberglass protected by a 1/8 -inch -thick
steel jacket. The car was 39 feet 4 1/2 inches long and its lightweight was 69,000 pounds.
The tank had an inside diameter of 98 inches, an inside length of 33 feet 8 1/2 inches and
was fabricated from American Society for Testing Materials (ASTM) A285 Grade C steel.
The tank head and shell thicknesses were 1/2 inch. The tank had a 20-inch manway
entrance, one 2 -inch water induction pipe, one 2 -inch phosphorous loading /unloading line,
one safety relief valve, and two 10 -inch top washout fittings. The car was equipped with
body-hung brakes 19/ with the brake cylinder and AB valve reservoir attached to two 6-
inch-diameter schedule 80 pipes welded directly to the tank shell.
The 2 -inch water induction pipe on UTLX 79499 was open, and the B-end top
washout nozzle and the tank shell adjacent to the airbrake support pipe were breached
during the derailment and subsequent fire. Also, the trailing B-end head received an
L-shaped tear at the 3 o'clock position which was 1 1/2 by 3/4 inches with less than
1/8 inch separation in the metal. (See figure 3.)
During the derailment, the leading truck of the tank car hit the south headwall,
disengaging the trucks and forcing the lead truck under the center of the car. As the tank
car detrucked, the underside attachments of the car were subjected to impact forces in a
rearward direction (from the A-end to the B-end) as it slid over debris. These forces,
when applied through one of the cylindrical brake supports, generated sufficient bending
19/ Refers to the practice on early design stub-sill tank cars of attaching airbrake
equipment directly to the tank shell at the bottom.
moments in the tank shell at the bottom of the tank to tear an 8 -inch -diameter hole in
the tank shell at the brake support attachment. Next, with the trailing end of the tank
car elevated and with the car still in an upright position, a passing car struck the body
bolster and trailing tank head puncturing a hole in the trailing B-end head at the 3 o'clock
position as viewed from the B-end of the tank car. The tank car then rotated
counter-clockwise, came off the bridge, and stopped abruptly at the south end of the
A 2-inch water induction pipe in the dome was found open with the plug valve
missing. There was fire damage to 3/4 inch of the thread at the end of the pipe. Also the
B-end washout, which was 10 inches in diameter and 6 inches in height, was damaged over
1/3 of its area.
UTLX 79499 was one of 32 similar DOT 103 tank cars built by UTLX for phosphorus
service and manufactured to the earliest stub-sill 20/ design in which the brake supports
were welded directly to the underside of the tank. In addition to UTLX 79499, Albright
and Wilson, Inc., operates four other tank cars that carry phosphorus. Two of these tank
cars were built by UTLX using the stub-sill design with body-hung brakes. The other two
were built by General American Transportation Corporation (GATX) which incorporated a
full-length center sill to which the airbrakes were attached. Following this accident,
UTLX notified lessees of similar UTLX 103 tank cars with the stub-sill design regarding
the Miamisburg incident, and many of these cars including those belonging to Albright and
Wilson have been voluntarily removed from service and returned for modification. After
learning of the Miamisburg accident, the Canadian Transport Commission (CTC) inspected
tank cars in Canada and found two similar UTLX tank cars in Canadian service. The CTC
ordered both of these cars taken out of service. While the Federal Railroad
Administration (FRA) has inspected similar cars in service, it has not required any to be
taken out of service nor does it intend to order any modification of similarly equipped
tank cars. Rather, it intends to monitor an industry-wide retrofit program being
developed by the Association of American Railroads (AAR) for unprotected body-hung
UTLX 76486. — This tank car was a 13,300 -gallon, DOT specification 111A100W4
tank car built by UTLX in 1974 specifically designed for transporting molten sulfur. The
car was equipped with 100 -ton trucks, type-F 21/ couplers and exterior heater coils. It
was insulated with 6 inches of fiberglass protected by a 1/8 -inch -thick steel jacket. The
car was 43 feet 10 inches long and had a lightweight of 63,000 pounds. The tank had an
outside diameter of 101 inches and was fabricated from ASTM A515 Grade 70 steeL The
tank head was fabricated of 15/32 -inch -thick steel, and the shell was fabricated of
7 /1 6 -inch -thick steeL The car was equipped with a stub-sill with the airbrake cylinder
attached to the stub-sill reinforcing pad.
Examination of UTLX 76486 disclosed that it had received three end punctures: the
trailing head had a 2 -foot -long fracture directly above the stub -sill, and the leading head
had a 10 -inch -diameter and a 28-inch long fracture. Its couplers and draft gears were
separated from the tank car while derailing. Nearly 50 percent of the outside jacket and
insulation of the tank car had been burned off.
20/ A short longitudinal structural member of a car underframe designed to
accommodate the coupler and draft gear and to transmit coupler forces to the car body on
cars designed with no through center sill.
21/ The type-F coupler was developed for general freight service and has the interlocking
or bottom-shelf feature that restricts vertical motion, thus resisting telescoping and
jackknifing in the event of a derailment.
UTLX 77400. — This tank car was a 22,000-gallon DOT specification 111A100W3
stub-sill tank car built by UTLX in 1969. It initially had been designed to transport
asphalt. The car was equipped with 100 -ton trucks, type-E top- and bottom-shelf
couplers, and exterior heater coils. It was insulated with 4 inches of fiberglass protected
by a 1.8-inch-thick steel jacket. The car was 51 feet 3 inches long, and its lightweight
was 75,600 pounds. The tank had an inside diameter of 113 inches and was fabricated of
ASTM A515 Grade 70 steel. The tank head was fabricated of 1/2 -inch -thick steel, and
the shell was fabricated of 15/32 -inch -thick steel. The airbrake equipment was mounted
on the draft sill. Examination of UTLX 77400 disclosed a hole puncture in the bottom
center of the tank head on the leading end, and the trailing coupler was broken at the
bottom knuckle pinhole.
Protection of Attachments. — Tank car manufacturers began to build stub -sill tank
cars of the type involved in this accident during the early 1960s. The stub-sill designed
for tank cars eliminated the full-length center sill beneath the tank previously used to
withstand the forces imposed by trailing loads and to absorb train draft and buff forces
generated during train operations not absorbed by the cushioning devices in the stub sill.
This design change also resulted in many of the attachments, 22^/ once made to the center
sill, including the airbrake cylinder and reservoir, being relocated and attached to the
tank. For several years at least three tank car manufacturers used a design attaching the
airbrake equipment supports directly to the tank car shell. After the cars were in service
for several years, it was noted that when a force was applied to an appurtenance as
happens during a derailment, the attachment would generate a bending moment into the
tank shell that could cause the shell to tear open.
In 1969 due to industry efforts to improve the performance of tank cars in
derailments, the AAR Tank Car Committee (see appendix D) required reinforcing pads
between the attachment and the tank shell. These pads were required to be at least
1/4 inch thick and to have a breakaway design capability. Concurrently, the subject of
impacts on tank shells and various appurtenances including tank fittings and attachments
for the various tank cars came under AAR study. The AAR also petitioned the FRA to
require similar protection for attachments on new tank cars tanks. In 1971 the FRA
changed its regulations on attachments as petitioned by the AAR, applicable only to new
tank cars built after 1971. In effect, more than 4,000 tank cars with brake equipment
supports directly welded to the tank were "grandfathered" by these requirements and were
allowed to remain in service unaltered.
In 1972 the Railroad Tank Car Safety Research and Test Project (Project), Railway
Progress Institute 23/ (RPI)-AAR cooperative program, completed its assessment of the
behavior of tank car tanks and their appurtenances in the mechanical environmental of
accidents. 24/ Its findings, based on a review of 1965 through 1970 accident data, showed
that when bottom discontinuities were struck, they acted as levers and tore the bottom of
the tank shell. While these data indicated that bottom fittings and attachments both were
vulnerable during derailments, the project found that the failure of bottom fittings
22 / Appurtenances attached to the tank shell and heads which are not associated with
openings through the vessel wall are tank attachments. Appurtenances attached to the
tank shell that are associated with openings through the vessel wall are tank fittings and
included items such as bottom outlets and washout gauging devices, top unloading nozzles,
and relief valves.
23 / Railway Progress Institute is an association of railcar and component manufacturers.
24/ RPI-AAR Final Phase 09, "Report on Tanks, Fittings, and Attachments in the
Mechanical Environment of Accidents," February 15, 1972.
accounted for the greater number of material releases from tank cars. The project's
assessment confirmed that the brake support bracket problem was primarily due to the
absence of a reinforcing pad. The project also identified additional considerations
including the need for local stress relief to compensate for problems that occur when
welding a bracket that supports a heavy load to the tank shell. These problems were left
to the car builders to handle, and as a result, the project did not recommend additional
requirements for design of attachments. It did, however, recommend that the behavior of
tank car fittings in accidents be docketed by the AAR Tank Car Committee for continued
After the tank car manufacturers began following the AAR's requirements for
installing reinforcement pads, metal fatigue problems were experienced with the
1/4 -inch -thick airbrake reinforcement pads. All but one car builder used shell plate
metal for making their pads, consequently the pads were greatly in excess of the 1/4 -inch
minimum thickness and these pads experienced no problems. The AAR later negotiated
with the one tank car builder to use pads of equivalent shell-plate thickness. The AAR
neither repetitioned or otherwise advised the FRA to change its tank car specifications
nor proposed additional design or fabrication requirements of its own for increasing the
required reinforcement pad thickness. Rather, the AAR relies on the tank car approval
process to ascertain that adequate thickness pad is being specified.
In 1974 the Tank Car Committee of the AAR approved protection specifications for
bottom outlets, washout, and sumps (discontinuities) for new stub-sill pressure cars
(classes 112A and 114A and the proposed class 120A). Concurrently, the subject of
bottom outlets on existing stub-sill tank cars came under study. In 1977 the committee
developed protection specifications for bottom fittings on new nonpressure stub-sill tank
cars. As of January 1, 1978, all newly built, low-pressure (less than 100 pounds working
pressure) stub-sill tank cars have been required to have bottom discontinuity protection if
the bottom discontinuities extended more than 1 inch. In 1980 the AAR committee
required protection of bottom discontinuities on existing class 112 and 114 stub-sill tank
cars used to transport liquefied gas or anhydrous ammonia. To develop a schedule of
priorities for retrofitting other existing tank cars with bottom discontinuity protection,
the committee appointed a task force of representatives from the railroads, the
Compressed Gas Association, the Chemical Manufacturers Association, the RPI, and the
AAR's Bureau of Explosives (B of E). The task force developed specifications to require
protection of bottom discontinuities on existing nonpressure, stub-sill tank cars used to
transport certain hazardous materials as listed in the eight AAR commodity groups. The
dates by which this protection must be provided were established for each AAR
commodity group with all protection required to be completed by July 1, 1990. None of
these protection requirements affected attachments to tank cars.
In it 1979 report which reviewed the FRA's hazardous materials program 25/ the
Safety Board recognized the progress made by the AAR for protecting bottom outlets.
However, because it recognized that the failure of bottom outlets was only one of several
tank car appurtenance failures capable of releasing hazardous materials from tank cars
during derailments, on March 20, 1979, the Safety Board recommended to the FRA:
25 / For more detailed information, read Safety Effectiveness Evaluation— "Review of the
Federal Railroad Administration Hazardous Materials Program and the Applicable Track
Safety Standards" (NTSB-SEE-79-2).
In cooperation with the [ AAR's] Inter -Industry Task Force, determine
what additional cost effective steps, based on risk-ranking results, can
be taken to make tank cars more resistive to hazardous materials
releases in derailments.
On October 12, 1979, the FRA responded that it was working closely with the AAR/RPl
Project which was directed at making tank cars more resistant to hazardous materials
releases in derailments. The Safety Board advised the FRA on May 12, 1980, that its
response failed to address the specifics of the recommendation. Additionally, the Safety
Board advised the FRA that Safety Recommendation R-79-24 would be classified as
"Open— Unacceptable Action" until the FRA provided a response that addresses the
specifics of the recommendation.
In its 1980 special investigation report 26/ the Safety Board examined the behavior
of derailed tank cars equipped with Safety Board-recommended shelf couplers, head
shields, and thermal coatings and compared their performance with tank cars not so
equipped. The report concluded that the recommended safety devices were effective in
minimizing the release of hazardous materials from tank cars so equipped. Further, the
report concluded that the majority of the breaches in the tank cars resulted from
damaged tank car appurtenances, primarily top fittings and bottom outlets.
In conducting its investigation, the Safety Board reviewed the actions being taken by
both the industry and the FRA. It was determined that the industry had proven the
technological feasibility for protecting bottom fittings (outlets) and had begun a program
to do so; however, the protection of top fittings had not received comparable attention
although the same technology could be applied to them. With respect to the efforts of the
FRA, the Safety Board determined that the FRA was not obtaining information on the
breach mechanisms of tank cars during derailments to assess the safety benefits or
liabilities of the regulations for tank car modification. The Safety "oard also found that
data being collected by the AAR/RPI on form BE/RA-49-79, "Owners Tank Car Damage
Report," neither documented the method of product of loss nor the events that caused the
release. Based on its finding that the FRA had not collected data on the effectiveness of
tank car protection nor had it documented how tank car product loss occurs in tank car
accidents on May 8, 1980, the Safety Board recommended to the FRA:
Cause data to be collected on tank car derailment behavior to identify
control methods, and incorporate findings in new car construction.
On July 18, 1980, the FRA, responding to Safety Recommendation R-79-24, stated
that it believed that the Inter-Industry Task Force could play a part in the process of
determining proper modifications to tank cars to reduce the incidence of hazardous
material releases in derailments. The FRA further advised that it had been working with
the Project since 1972. The FRA believed the Project was the key body for achieving
results because the Project, as opposed to the Inter-Industry Task Force, had the required
knowledge, expertise, and ability to bring about necessary improvements in tank car
26 / For more detailed information, read Special Investigation Report— "The Accident
Performance of Tank Car Safeguards, March 8, 1980," (NTSB-HZM-80-1).
On August 8, 1980, in response to Safety Recommendation R-80-14, the FRA
advised the Safety Board that it was researching and testing the mechanisms involved in
the breaching of tank cars, but it provided no details on these efforts. The Safety Board
classified this recommendation as "Open— Unacceptable Action" and informed the FRA
that its reply failed to address the recommendation in that no action was cited relative to
the FRA's collection and use of data or identifying breach mechanisms.
In its June 8, 1981, followup letter to the FRA on several recommendations
including R-79-24, the Safety Board noted that the Inter-Industry Task Force had been
dissolved. However, before dissolution a System Safety Analysis Subcommittee had been
established under a cooperative agreement between the AAR and the Chemical
Manufacturers Association to continue analyzing available rail accident data to make
certain that the findings from the analyses were translated into increased rail safety. The
Safety Board acknowledged the FRA's statement that the FRA had been working jointly
with the Project to develop cost-effective improvements to tank cars and requested the
FRA to keep the Safety Board informed about progress made. In the interim, the Safety
Board classified Safety Recommendation R-79-24 as "Open— Acceptable Alternate
On July 14, 1982, in response to Safety Recommendations R-79-24 and R-80-14, the
FRA advised the Safety Board that the AAR had voluntarily established retrofit
requirements for bottom outlet protection of all stub-sill tank cars that transport
hazardous materials. Because of extensive voluntary actions, the FRA advised that it did
not believe that regulations for bottom valve outlet protection were warranted. The FRA
further advised that its review of accident data concerning the protecting of top fittings
did not indicate sufficient justification for further regulations; however, it advised that
the industry was considering the establishment of limitations of their maximum height.
The Safety Board evaluated these two actions as a good -faith showing by the FRA that it
was concerned about the consequences of appurtenance failures and that it was active in
seeking improvements. Therefore, on October 4, 1982, the Safety Board classified Safety
Recommendations R-79-24 and R-80-14 as "Closed— Acceptable Action."
On May 2, 1980, following two accidents involving airbrake attachments, the
Seaboard Railroad (SBD) (now a part of CSX) requested the AAR to again review the
accident history of cars with brake support equipment welded directly to the tank shell.
The SBD reported that as a result of a 21 -car derailment at Buckhead, Georgia,on
April 19, 1980, the brake equipment of a liquefied petroleum gas (LPG) tank car was torn
off leaving two holes in the shell about 11 inches in diameter. Immediately following the
derailment, the LPG burst into flames and burned for 4 days. The SBD investigation
determined that the use of a reinforcing pad between the tank shell and the brake support
could have prevented the LPG release and fire. The SBD added that "this situation is no
different from having bottom outlet broken off in a derailment and should be treated
similarly." SBD added that in 1973 it experienced an incident in which a tank car lost its
airbrake support brackets.
The AAR referred this request to its Tank Car Committee which responded to the
Union Tank Car Company built 1,842 tank cars between 1963 and 1966
with similar brake equipment support arrangements and voluntarily
discontinued using this design. Since there were no AAR or DOT
requirements prohibiting such arrangements at that time ... it was the
opinion of the subcommittee that remedial action is not warranted at
this time since a large number of similar tank cars have been in service
for so many years without experiencing similar damage. The Buckhead
incident is the only reported puncture associated with this design.
In 1983, the RPI/AAR Project made an assessment 27/ of the 1965 through 1980
AAR accident data and found that 20 tank cars had released hazardous materials due to
attachments failures; 8 of the 20 attachment failures were at brake supports. However,
the Project again maintained that there had been so few cases where attachment failure
had been involved that no attempt had been made to examine the damage and design in
detail in order to estimate if a change would have prevented the tear.
As a result of the Miamisburg incident, the AAR Tank Car Committee has changed
its viewpoint in regard to protecting bottom attachments. The committee has now
required a retrofit of the existing fleet of 3,630 tank cars that were built with unpadded
body^lung airbrake attachments. Specifically, the committee now has approved proposals
to modify the tubular brake equipment supports on a product hazard basis, beginning with
the pressure cars and progressing through the material hazard rankings until, at the end of
a 5-year-period, the entire group of cars would be modified, down-rated to carry
nonregulated commodities, or scrapped. The modifications would consist of replacing the
airbrake support bracket with a pad and new pipe designed to safely break away. The
committee has also initiated a study of its accident review procedures and a study of the
Project's 1972 and 1983 reports for possible future activity.
Development of Tank Car Safety Standards
Tank car safety problems identified during the Miamisburg accident and in previous
Safety Board investigations of accidents at Marshville, North Carolina; North Little Rock,
Arkansas; Elkhart, Indiana; and Seattle, Washington; 28/ and other accidents all combined
to prompt a Safety Board review of the process by which tank car safety standards have
been developed and how deficit conditions are identified and corrective actions
implemented. The Safety Board reviewed the history of tank car development, studied
the Federal and industry safety standards for tank cars, and formed an investigative group
consisting of the FRA, the AAR, and the CTC to collect information on the procedures
used by each agency in formulating safety standards for tank cars. On April 9, 1987, the
group met to discuss the tank car safety programs and to identify interactions among
those agencies. Appendix D contains a description of the FRA delegations of authorities
to the AAR for tank car safety, a description of the present AAR processes for
implementing these delegations, and a description of the monitoring performed of the
Initial Tank Car Safety Program .— Early development of tank car safety standards
began when the Interstate Commerce Commission (ICC) was authorized by a 1921 law (41
Stat. 144) to use the services of the ARR's Bureau for the Safe Transportation of
Explosives and Other Dangerous Articles (now the B of E) for carrying out its
27/ RPI-AAR Phase 02, "Report on Analysis Non-Pressure Tank Car Behavior in
Accidents," March 24, 1983.
28/ For more detailed information, read Railroad Accident Reports— "Seaboard System
Railroad Freight Train FERHL Derailment and Fire, Marshville, North Carolina, April 10,
1984," (NTSB-RAR-85-5); "Hazardous Materials Release, Missouri Pacific Railroad
Corporation's North Little Rock, Arkansas, Railroad Yard, December 31 1984,"
(NTSB-SIR-85-3); "Anhydrous Hydrogen Release from NAIX 9408, Train No. BNELY3Y at
Conrail's Receiving Yard, Elkhart, Indiana, February 4, 1985," (NTSB-HZM-85-3).
responsibilities for developing tank car safety standards. A 1979 U.S. Senate
report, 29/ reviewing and analyzing the DOT's hazardous materials transportation safety
regulatory program, stated, "The ICC took this Congressional authorization literally; it
practically turned the hazardous materials transportation safety program, including tank
car safety standards, over to the AAR's Bureau of Explosives."
In 1960, the ICC law was amended (Public Law 86-710) by among other changes
authorizing the ICC to use the services of carrier and shipping associations in its
hazardous materials safety program. Again, according to the 1979 report, "The ICC took
this authorization literally, turning to the trade associations particularly in the
development of the requirements for the larger containers, such as tank cars and tank
trucks." The report stated that the ICC did not have sufficient expertise to analyze the
industry recommendations and the ICC did not establish criteria or procedures to guide
the industry in its development of standards. Generally the ICC accepted without
question the industry-developed standards.
FRA Tank Car Safety Program .— In 1966 the U.S. Congress created the DOT and
transferred to it all safety regulatory authority for the transportation of hazardous
materials formerly vested in the ICC, the Federal Aviation Administration, and the U.S.
Coast Guard. However, the delegations of authority to industry organizations and the
existing industry -oriented framework in which most of the regulations for the
transportation of hazardous materials had evolved remained essentially unchanged.
By the time the hazardous materials safety program of the ICC was transferred to
the DOT, the ICC had delegated hundreds of responsibilities to the AAR, among them the
responsibility for tank car safety. Responsibility for carrying out the DOT's authority
over tank car safety was assigned to the FRA, and it continued the delegations of
authority made by the ICC. The FRA continued to have exclusive responsibility for tank
car safety standards until July 1975, when the Secretary of Transportation created the
Materials Transportation Bureau (MTB) 30/ and designated it as the lead agency for the
DOT's hazardous materials transportation safety program. Its responsibilities now are
administered by the RSPA. While the MTB was given responsibility for issuing all
regulations affecting the transportation of hazardous materials, the initiatives for
developing regulations applicable to a single mode of transportation was left with the
modal DOT administrations; thus, the FRA continued to be the responsible agency within
the DOT for rail tank car safety standards.
Since 1966 RSPA has withdrawn from the AAR and others more than 500 delegations
of authority; however, the FRA has continued virtually unchanged the delegations of
authority to the AAR for tank car safety. Like the ICC, the FRA did not establish
criteria or substantive procedures to guide the AAR in its implementation of the
The regulations (49 CFR 179 and 173.31) include the DOT's specifications for tank
cars; delegations to the AAR for approving designs, materials, construction, conversion,
and alteration of 10 ears; certification requirements; provisions for service trials 31/ of
29/ Congressional Research Service, Library of Congress, "Hazardous Materials
Transportation: A Review and Analysis of the Department of Transportation Regulatory
Program," April 1979.
30/ The MTB no longer exists. The hazardous materials responsibility previously managed
by the MTB was made a responsibility of the Office of Hazardous Materials which was a
suborganization of the MTB.
31/ These service trials refer to a DOT exemption process and are different from the
"AAR service trials of values and fittings" that were allowed under the regulations.
tanks and equipment that do not conform to DOT regulations; delegation to the AAR for
developing recommended changes or additions to the DOT specifications for tank cars;
and some general actions to be taken by the AAR in carrying out the delegations of
authority. For example, the car builder must build the car according to the approved
drawing and follow requisite AAR-specified inspections. The regulation requirements do
not address matters such as the qualifications or interests represented by persons serving
on AAR committees that carry out the delegated responsibilities, the procedures or
analyses to be followed by AAR committees in making determinations about the adequacy
of designs and modifications approved to meet public safety needs, the documentation
requirements in support of decisions made, or other procedural matters related to the
implementation of the delegated authority. The regulations establish only one
requirement for the AAR to report to the DOT the actions it has taken under the
delegated authority — to report its recommendations about proposed changes or additions
to DOT specifications for tank cars. The FRA does not have procedures for monitoring
the actions taken by the AAR under the delegated authority.
The Safety Board previously directed the FRA's attention to the fact that neither
the FRA nor its delegated agent, the AAR, inspects the work of tank car manufacturer's
to determine if tank cars are being constructed in compliance with DOT regulations and
AAR Tank Car Specifications. Based on its findings as a result of its investigation of a
December 31, 1984, ethylene oxide release at North Little Rock, Arkansas, the Safety
Board recommended that the FRA:
Institute an inspection program to verify that tank cars intended to be
used in hazardous materials service are manufactured in compliance with
Department of Transportation standards.
On February 18, 1986, in response to Safety Recommendation R-85-99, the FRA advised
the Safety Board that it was working on a plan to address the inspection of tank cars
during their manufacture and that when the plan was complete, it would be provided to
the Safety Board. On December 2, 1986, the FRA provided a copy of a proposal to
perform a review of the AAR Tank Car Committee process and of new construction,
repair, and alteration facilities for tank cars. This proposal included the following list of
"points to be reviewed," which provides insight into previous actions by the FRA for
monitoring the activities of the AAR in carrying out the FRA-delegated authorities:
o Are applications for tank car construction and modification
o Is the review thorough, and is there a procedure or form used as a
check list to assure that all pertinent information has been
furnished on the application?
o How often does the committee meet?
o How often are AAR-certified shops inspected?
o How does the Tank Car Committee decide what is to appear on
their dockets for discussion?
o Is there any procedure established to inform RSPA/FRA of possible
problems in specific design issues or other matters that would be of
concern pertaining to safety (i.e., cracking of stub-sills, corrosion,
o Who decides when a docket is satisfactorily completed? Is it by
majority of all voting members?
o Does one negative vote reject an application, certification, or
o How are materials, appurtenances, gaskets, valves, etc., approved?
o Are outside consultants used in evaluating tank car designs,
materials, appurtenances, etc.?
o What criteria are used to nominate committee members?
o How often are Chairmen chosen and what is the procedure?
o Is there any mechanism to remove a committee member who is not
As a part of the FRA committee's current actions during 1987, answers to these
questions are to be obtained by reviewing the AAR's Washington office records and
procedures, interviewing at least two Tank Car Committee members, inspecting at least
two tank car manufacturing/repair facilities, and inspecting the procedures used by two
major tank car builders for submitting to the Tank Car Committee for approval of
applications for construction of tank cars and for repairs or alterations to tank cars. The
FRA estimated that this review would be completed the fall of 1987.
The Safety Board was provided during its review, an August 27, 1986, letter from
the FRA's chief counsel to the AAR which discussed the nature and scope of the major
delegations to the AAR Tank Car Committee under the DOT's regulations.
The Department's authority under the Hazardous Materials
Transportation Act to "issue regulations for the safe transportation in
commerce of hazardous materials, 49 U.S.C. §1804," rests with the
Research and Special Programs Administration. RSPA has delegated
certain specific functions to the Tank Car Committee, e.g., 49 C.F.R.
There are two general characteristics of such delegations. First, any
action by a delegate acting in that capacity is wholly circumscribed by
the scope of the delegation. Thus, any act putatively within the
delegated capacity, but actually outside the scope of the delegation, is
without legal affect. Second, since delegations are revocable at any
time, publication of a notice of proposed rulemaking revoking a
delegation is not required if the delegation is published in the Code of
The letter then described the FRA's understandings of the delegated authorities.
It is especially significant that the Department has delegated to the
Tank Car Committee the responsibility to approve or reject an
application for the design, materials and construction, conversion or
alteration of tank car tanks based on the provisions of 49 C.F.R. Part
179, Specifications for Tank Cars.
The letter explained that the Tank Car Committee exercises no discretion in the
referenced approval process since any application in compliance with effective
regulations and specifications "will be approved" and any applications not in compliance,
cannot be approved; for these, the committee could only recommend service trials.
The FRA chief counsel noted that even should the Tank Car Committee approve a
noncomplying application, this does not permit the person receiving the approval to
violate the DOT's specifications by issuing a certificate of compliance for a tank car when
the tank car does not meet the DOT's specifications. The Tank Car Committee's actions
under the delegated authority were characterized as serving the interests of the DOT in
using its expertise to screen out noncomplying applications. The letter specifically
pointed out that a tank car builder may not use the Tank Car Committee's approval to
operate a tank car that violates DOT specifications, and that the DOT is free to act to
correct an improper Tank Car Committee approval.
The FRA's general counsel described other delegations to the Tank Car Committee
as having the authority "to approve designs or materials other than those specifically
prescribed by a particular rule." It was noted that "such delegations vest discretion in the
Tank Car Committee, but only as to the specific subject covered by that Section."
Additionally, by FRA adoption of appendix R of the AAR Tank Car Manual, repairs and
alterations of tank cars performed in accordance with appendix R are also governed by
During the April 9, 1987, meeting conducted by the Safety Board, the FRA advised
that it currently was reviewing the AAR operations. Other than the present review, the
FRA monitored AAR under the FRA-delegated authority by reviewing FRA
accident/incident data; inspecting tank car facilities (begun in 1983); attending AAR Tank
Car Committee and Hazardous Materials Steering Committee meetings; and
communicating daily with the AAR both by telephone and through written
communications regarding a variety of safety issues. However, of the three
representatives of the FRA attending the April 9, 1987, meeting, none could attest to any
actions by the FRA for reviewing the records of the AAR or for monitoring the various
delegated activities carried out by the AAR since 1976, the earliest time any of the three
had responsibilities for tank car safety. Also, none of the representatives could recall
written procedures or an FRA policy for monitoring the activities of the AAR as they
relate to the delegated authorities. Finally, the AAR representative at the April meeting
could not recall any requests by FRA representatives to review AAR records or to
monitor the Tank Car Committee activities.
AAR Tank Car Safety Program. — The Tank Car Committee is the entity in the AAR
responsible for carrying out the FRA-delegated authorities on tank car safety. The Tank
Car Committee bases it approvals of tank car designs, modifications, and alterations on
current DOT and AAR requirements. (See table 1.) The Tank Car Committee also is
charged with reviewing requests for changes or additions to the specifications for tanks,
considering the recommendations of its Subcommittee on Specifications, and reporting its
recommendations to the DOT. (The DOT regulations, as a part of its delegation to the
AAR, require that the Subcommittee on Specification review proposals for new tank
Table 1.— AAR/TCC Flow Chart - Application for Approval of Tank Car Construction
Tank Car Builder
Tank Car Committee Distribution
And Review Process 12 Members
(Excluding RPI Representative)
Signed Certificate of
Construction That Car
IVIeets Both AAR & DOT
specifieations and make recommendations to the Tank Car Committee on proposed
additions and changes. Although incorporated within the requirements of the delegated
authority, this Subcommittee was abolished in 1972 under a structural reorganization
effected by the AAR's Director of Technical Committees. The AAR representative
advised that "this subcommittee had functioned at least since 1956 as the total group of
interested parties who formulated proposed revisions to the Specifications for Tank Cars
for review and approval by the Tank Car Committee." The AAR representative added
that this group is still in place and is now called "Subcommittee 1 and 2, Working Groups"
and are studying proposals in specialized areas.)
According to the AAR, members of the Tank Car Committee must have direct
technical expertise in hazardous materials transportation and are appointed by the
General Committee of the ARR's Mechanical Division from nominations made by railroads
and others. (The AAR representatives stated that qualified individuals representing
general public interests could be appointed; however, such a nominee has never been
considered.) The AAR now authorizes the Tank Car Committee to have 16 voting
members (10 from railroads, 1 from RPI, and 5 from chemical manufacturers and tank car
owners and 1 representative of the AAR's B of E, who is a nonvoting member. This
organization reflects recent changes of the committee developed to strengthen the
railroad industry's influence in the tank car standards, to provide railroad industry
experience on all aspects of tank car safety rather than so ley tank design, and to ensure
more active participation by the railroad members. The voting members vote "according
to the dictates of the technical expertise they possess as related to the issue before the
committee." The AAR's recent changes in this committee's structure also included a
requirement that the chairman be selected from the railroad membership and added a
cochairman who also must be selected from the railroad membership.
The AAR stated that its procedures for the Tank Car Committee are conducted by
Robert's Rules of Order, agendas for meetings are prepared and distributed, and minutes
of the meetings are recorded. For items to be considered by the committees, there must
be a quorum or simple majority of voting members present. Items are approved when a
majority of members present consent. There are no limitations concerning the number of
members on the Tank Car Committee who represent the same organization.
In 1986 and previous years, the Tank Car Committee was authorized to have 13
voting members any of whom could serve as its chairman. The B of E had a nonvoting
member. Seven members were required to be selected from railroads, one from the RPI,
and the remaining five from nonrailroad trade organizations. This organization was
believed to provide a reasonable balance: the railroads are responsible for the safe
transportation of hazardous materials and in general are economically responsible for the
effects of releases; the shippers and owners of tank cars may desire to maximize the
amount of product that can be transported in tank cars given the gross weight limitations
imposed by the rail system design; and the tank car builders are responsible for the design
and manufacture of the tank cars. The AAR representative stated that trends in the
voting had been noted wherein some of the railroad members were not active in reviewing
and voting on the 400 to 800 applications that are handled by the Tank Car Committee
every year by mail. To secure approval by letter ballots 32/ for constructing tank cars on
a timely basis, AAR staff sometimes had to actively solicit railroad member votes since
at least one railroad member had to vote for the ballot to represent a majority of the
votir^ members. Inactivity by the railroad members in voting on these letter ballots
32 / Tank Car Committee approval of an application by mail requires both a majority vote
and no negative ballots cast by the members.
could result in an item being approved by members representing chemical manufacturers
and tank car owners.
The AAR representative stated that the railroad members are fully informed and
active in voting on major issues at Tank Car Committee meetings. The representative
further noted that at meetings when a majority of voters approved an item, but the
approving votes were not balanced among the varied interests, approval of the item
normally would be withheld by the direction of the chairman until the proposal could be
modified and a consensus achieved.
Safety Board requests made in March 1987 to inspect AAR records as a part of its
investigation were denied by the AAR. Later, limited access was granted and the AAR
explained that it had hesitated primarily because no one outside the AAR had ever
requested to review these records; thus, it had never formulated a policy on allowing
others to have access to its records. Minutes and other records of the Tank Car
Committee now are available to qualified Federal government representatives for review;
however, this policy was only established by the AAR after the Safety Board made its
March 1987 request.
The Canadian Transport Commission
Primary responsibility for railroad tank car safety in Canada is vested in the CTC.
It, like the FRA, has delegated responsibilities to the AAR Tank Car Committee, tank car
owners, railroads, shippers, and other organizations such as the Chlorine Institute,
Canadian Compressed Gas Association, Canadian Fertilizer Institute, and the Propane Gas
Association. The CTC adopts as its requirements most of the provisions of 49 CFR Part
179 on tank car specifications; however, for tank cars in Canadian service, it goes beyond
these requirements by:
o requiring full head shields on newly built pressure tank cars where
head protection is required;
o prohibiting the use of ASTM A515 steel in its present form on any
newly built tank cars;
o requiring thermal insulation on cars carrying most of the liquefied
o requiring an orange colored bank on certain compressed gas tank
cars to assist in identifying these tanks cars.
Identification of tank car deficiencies and determinations about safety
improvements usually occur as a result of accident and incident investigations and as a
result of independent actions taken by the CTC based on information gained through
public hearings or information developed on perceived safety threats. Safety
improvements identified are implemented by ordering retrofits or, when a tank car
manufacturer is cooperative, by periodically monitoring the progress of voluntary actions
The CTC presently inspects tank car manufacturers infrequently and usually does so
as a result of accidents or incidents; however, the CTC is formulating a formal program
for determining that manufacturers comply with its regulations. The CTC advised that its
interface with the AAR and the FRA was informal and irregular, that the CTC had only
limited access to any AAR records, and that the CTC had never attempted to obtain any
FRA records officially. However, the CTC representative participating in the Safety
Board's review of the tank car safety programs expressed the CTC's believe that the
interface among the CTC, the FRA, and the AAR should be formalized and strengthened
to identify and resolve common safety problems associated with tank cars. Common
safety problems cited as requiring coordinated efforts among the three agencies were:
(1) improving safety relief valves in anhydrous ammonia service; (2) providing
reinforcement pads on some tank cars; and (3) improving the quality of workmanship in
some tank car shops.
In its February 26, 1987, resolution to the CTC, the Canadian Immediate Response
to Railway Accidents Technical Experts (IRRATE) 33/ supported the view that increased
cooperation among the CTC, the FRA, and the AAR was necessary for improving tank car
safety. That resolution called for:
... a serious attempt to be made to form a joint regulatory group
between Canadian and U.S. authorities which should review the adequacy
of the regulations periodically, assess proposals for any regulatory
changes, and assure that any changes are implemented in the same
manner and at the same time by the regulatory authorities of Canada
and the U.S.
Findings from an investigation on the February 28, 1984, failure of a tank car at a
railroad yard in Vaughan, Ontario, Canada 34/ greatly influenced the efforts of the CTC
to formalize a monitoring program for covering the responsibilities of the AAR and
others. The tank car failure in Ontario resulted from the propagation of a preexisting
welding-related defect that occurred during the manufacture of the tank car but was not
detected by tests and inspections performed before the tank car was placed in hazardous
materials transportation service. Since the failure involved problems potentially related
to the performance of rail-related industry groups in carrying out delegated
responsibilities, the investigation also looked at the CTC's regulatory program of CTC and
at its monitoring of the delegated authorities.
The investigative effort recognized that Canadian action by itself would not
effectively provide the measures necessary to ensure public safety. It also recognized
that many tank cars were in daily use transporting hazardous materials to and from the
United States and that the CTC with its limited resources likely would be unable to
effectively monitor delegated activities performed outside of Canada. Consequently,
CTC concluded that it needed to develop an arrangement with "those in authority, and
those involved in tank car manufacturing in the United States as well as in Canada in
order to ensure consistency of control over-border tank car usage."
Appendix G provides the investigative report discussing the CTC's relationship with
the AAR. In part this segment of the report concludes:
Recognition that the performance standards for all safety devices and
tank car retrofit proposals requires re-evaluation on a cost/benefit/risk
33/ Resolution: Immediate Response to Railway Accidents Technical Experts (IRRATE),
Item 2-87, February 26, 1987.
34/ Report of the Inquiry into the Failure of Tank Car UTLX 98646 on February 28, 1984,
in the Canadian National Railway Company's MacMillan Yard, in the Township of
Identification that the CTC needs to have liaison with the FRA, the
AAR, and others whose actions affect tank car safety;
Recognition that the initiative for tank car safety improvements most
always rests with the AAR;
Recognition that there is no contribution to the AAR's deliberations on
behalf of the Canadian public;
Identification that resolution of safety problems recognized in Canada
seem to be left to the AAR Tank Car Committee;
Documentation that the AAR is a self-regulating agency operating in a
geographical territory over which no single regulatory body had complete
jurisdiction, that the AAR performs both coordinating and technical
functions for assistance both to its members and any other group that
requires the AAR expertise, and that [the AAR] is able to draw upon a
substantial body of technical knowledge and expertise;
Recognition that an AAR standard, on the average, may be acceptable to
the Tank Car Committee members and to their respective
'constituencies' but these individuals may or may not always include
Canadian interests and concerns;
Identification that a means must be developed for reviewing and
evaluating AAR standards on behalf of the Canadian public;
Recognition that by substituting a new formal structure for the present
ad hoc Canadian surveillance and regulation of design specification
standards that originate with the AAR will better serve to protect the
safety of the Canadian public.
Case History: FRA Oversight of AAR Tank Car Safety Activities
Early nonpressure stub-sill tank cars manufactured by GATX tended to buckle in the
shell of the tank as a result of buff forces, the longitudinal forces generated during train
operations. These tank cars were experiencing localized buckling near the inboard ends of
the draft sills. If damages occurred during normal operations and the tank car was
designed and constructed according to AAR standards, the railroads were required to pay
for the damages incurred.
In response to an AAR-member railroad report of incidences of tank car buckling,
the AAR reviewed these incidents and its design standards. The AAR Car Construction
Standards Committee determined that its 800,000-pound compressive end-load
criteria 35/ for railroads should be increased and on July 1, 1974, established a
1,000,000 -pound compressive end-load standard. While the rail industry through the AAR
did not require tank cars to be modified to the new AAR draft loading standards, at that
time it was made effective for new and rebuilt status cars and for those car owners who
wanted protection under the interchange rules for buckling damages. Under interchange
rules, railroad liability was limited to those cars that were retrofitted to meet the new
1,000,000-pound draft standard.
35/ Draft, buff, compressive, and impact loads were all increased at this time.
To comply with this new standard, GATX qualified a design that modified existing
noncomplying tank cars by longitudinarily attaching to the underside of the tank two
parallel steel bars located 16 inches apart. (All owners of these tank cars did not elect to
retrofit their tank cars. However, in response to the occurrence of several spectacular
buckling incidents involving empty tank cars, in 1985 the AAR issued a requirement that
tank cars not presently complying with the new loading standard must be retrofitted to
meet this standard by 1989.)
To meet the 1974 end-load requirements for newly manufactured tank cars, GATX
modified its design by incorporating the reinforcement bar retrofit design such that it
could withstand the new end-load requirements. Under this revised design, RAIX 7033
was manufactured by GATX in January 1976 as a DOT Specification 111A100W4 tank car
specifically for the transportation of ethylene oxide. This design also included the
attachment of a jacket anti-shift bracket welded directly to the tank shell. The anti-shift
attachment used by GATX violated a November 6, 1971, Federal and 1969 AAR
requirement specifying that reinforcing pads must be used between external brackets and
shells if the attachment weld exceeds 6 linear inches of 1/4-inch weld fitted, that
reinforcing pads must not be less than 1/4-inch, and that the ultimate shear strength of
the bracket-to-reinforcing pad weld must not exceed 85 percent of the ultimate shear
strength of the reinforcing pad-to-tank weld. (GATX reported that from 1971 through
1981, more than 9,810 tank cars were equipped with anti-shift bars welded directly to the
bottom of the tank shell under AAR-approved certificates for construction.) GATX noted
that during this period the company's construction drawings were not updated to reflect
the November 6, 1971, change in the DOT tank car safety standards.
Because of Federal requirements under HM-175 for retrofitting certain tank ears
with insulation and puncture protection for the ends of tanks, modification of this tank
car was required. North American Car Company (NATX), an AAR-approved tank car
fabricator, submitted an application to the AAR on September 29, 1981, to make the
Federally -mandated modification for adding head protection and insulation. On
December 14, 1981, the AAR Tank Car Committee approved NATX's requested
modification as meeting both AAR and DOT requirements.
Modification of RAIX 7033 in accordance with the AAR-approved drawing was
completed on December 3, 1981. This AAR-approved tank car repair facility did not
recognize that the anti-shift bracket installation did not comply with the existing Federal
standards for protecting attachments. A representative of the repair shop stated that its
responsibility is to ensure that a car meets all AAR requirements and regulations, but it
does not question the design of the car. If there is a problem, the repair facility will
notify the car owner and obtain approval to fix it.
Records concerning the history of this tank car show that on April 25, 1983,
stiffener bars were welded to the steel jacket of RAIX 7033 on each side of the anti-shift
bracket. While it was not possible to determine precisely why this work was performed,
the modification strengthened the steel jacket in the area of the anti-shift bracket.
Apparently, stabilizing the movement of the jacket in relation to the tank had been
difficult, and this action had damaged the jacket in the area of the anti-shift bracket.
(The idea that the anti-shift bracket was not adequate to stabilize the jacket was
supported on January 17, 1985, by the Safety Board's documentation of damage to the
jacket in the area of tank bolster plate.)
On December 31, 1984, ethylene oxide was discovered to be leaking from RAIX 7033
while it was located in a railroad yard at North Little Rock, Arkansas. The Safety Board's
investigation of this incident concluded that the ethylene oxide had leaked from
RAIX 7033 as a result of two through-shell cracks near the center of the bottom of the
tank at each extremity of the welds on the anti-shift bracket, that the cracks resulted
from the forces transmitted to the tank through the anti-shift bracket when the jacket
moved relative to the tank during normal operations, that the welded connection of the
anti-shift bracket was installed in violation of Federal standards, and that neither the
AAR nor the FRA monitor manufacturers of tank cars for compliance with DOT tank car
design, standards, and proper construction methods.
During the Safety Board's investigation of the North Little Rock, Arkansas,
accident, it learned that on April 1, 1985, GATX submitted to the Tank Car Committee
for approval an application to modify four tank cars similar to the design as RAIX 7033,
but not including RAIX 7033, in order to remove that portion of the existing anti-shift
bracket in excess of 2 inches below the tank and then attach a new anti-shift jacket
bracket either to the existing tank stiff ener bars on the bottom of the tank or, for those
tanks not equipped with tank stiffener bars, to airbrake cylinder supports attached to the
tank by the use of a reinforcing pad. Through this application, GATX sought to obtain a
"precedent" for modifying similar noncomplying tank cars. In securing a "precedent"
approval, GATX would then have been allowed to modify all other similarity noncomplying
tank cars by filling an Exhibit R-1 with the AAR and:
o without further review and approval by the Tank Car Committee
since it was a previously approved procedure;
o without complete removal of the noncomplying anti-shift anchor in
accord with the procedure;
o without having to notify the FRA of the modifications to the tank
o by using repair methods approved in AAR's 1985 appendix R which
had not yet been approved by the FRA. (This would have allowed
GATX to X ray and postweld heat treat only those weld repairs
3/16 inch in depth or 6 inches in length.)
The AAR Tank Car Committee declined to approve the GATX application as
submitted and requested GATX amend its application by including x ray and stress relief
for welded repairs of tank cars transporting products under pressure. On April 9, 1985,
GATX submitted the requested changes and on April 12, 1985, by telephonic balloting of
Tank Car Committee Members, the application was approved. However, on
April 15, 1985, the chairman of the Tank Car Committee in casting a negative note
requested additional clarification of the GATX application; his position was that if either
the 3 /1 6 -inch depth or the 6 -inch length of crack were exceeded, then postweld heat
treatment and x ray would be required on all weld repairs. On April 19, 1985, GATX again
revised its application incorporating the changes requested by the chairman of the Tank
Car Committee. On April 22, 1985, the GATX application was again approved by the
committee as being, in their opinion, in compliance with AAR and Federal requirements.
On May 6, 1985, GATX voluntarily submitted a self-generated revision to its application
to modify the size of the hole required in the tank car jacket for performing the
modifications previously approved by the AAR.
On May 17, 1985, the Safety Board made two recommendations to the FRA because
of additional information gained during its continuing investigation of the
December 31, 1984, incident related to RAIX 7033, the large number of tank cars
equipped with anti-shift brackets similar to RAIX 7033, and the fact that FRA had taken
no action concerning the modifications being proposed by GATX. These two
Require inspection of all jacketed cars in hazardous materials service
that have anti-shift brackets protruding outside the tank jackets for
indications of jacket shifting or product seepage in the anti-shift bracket
area, and remove from service all cars that exhibit symptoms of such
distress until approved repairs are made.
Evaluate for adequacy and timeliness, directing changes as necessary,
the General American Transportation Corporation's proposed inspection
and repair program for bringing tank cars on which anti-shift bracket are
welded directly to the tank shell into regulatory compliance, and monitor
the completion of the program.
In response to these recommendations, on June 12, 1985, the DOT issued a notice
requiring that the DOT specification stenciling be removed from all GATX tank cars that
have the anti-shift anchor welded directly to the tank shell. It also directed that the cars
be removed from hazardous materials service and not be returned to hazardous materials
service until action had been taken to bring the cars into compliance with Federal
regulations. Concurrent with its notice, the DOT formally advised each car owner and
lessee that they had 10 days to return affected tank cars to their destination in empty
condition for making repairs. Also, the DOT requested to be advised about the retrofit
schedule and field repairs.
In response to the DOT notice, car owners and lessees began advising the DOT that
to comply with its order they would experience extreme hardships because a large
percentage of tank cars in their fleets would be affected by the order. The DOT received
requests for exemption to the order as early as June 17, 1985. Included with some of the
petitions for exemption were GATX's April 9, 1985, application for repairs that had been
approved by the AAR.
In response to the requests for exemption, between June 19, 1985, and July 8, 1985,
RSPA granted exemptions affecting more than 800 tank cars. This allowed tank cars
other than those used for transporting flammable gases to continue transporting hazardous
materials through September 15, 1985, provided they were marked with the exemption
number and that they were inspected to determine that there was no evidence of leakage
in the area of the anti-shift anchor or shifting of the jacket. In granting an exemption to
the Union Oil Company, RSPA noted that three LPG tank cars were included that already
had been modified in accordance with the April 9, 1985, GATX modification approved by
the AAR. The FRA, in its July 1, 1985, memorandum to RSPA, recommended including
the three LPG cars under the exemption even though the FRA recognized that the
modification did not comply with DOT requirements. The FRA noted that the
noncompliance was because the anti-shift anchor had not been fully removed. The FRA
favored including these cars in the exemption because it believed the modifications had
reduced substantially the likelihood of tank failure as a result of the tank being torn by
Late in June and early in July 1985, the FRA began receiving information it had
requested from tank car owners and lessees concerning the retrofit schedule field repairs.
At this time, FRA determined that 400 tank cars were being retrofitted by just cutting
off a portion of the noncomplying anchor and leaving a stub on the tank. The FRA
informed the AAR and GATX that these 400 tank cars would have to be removed from
service and tested for cracks in the area of the anti-shift anchor stub. It further informed
them that the April 9, 1985, AAR-approved modification did not comply with DOT's
interpretation of its requirements and that it did not recognize as acceptable the use of
defect-size criteria other than that incorporated in appendix R of the 1982 Edition of
AAR's Manual on Tank Cars for Specification.
On July 31, 1985, in response to the FRA concerns, GATX submitted to the AAR
Tank Car Committee a fourth revision to its application for modifying the tank cars. This
revision included a proposal to use a surface grinding method for repairing partial-depth
cracks by grinding up to 1/1 6 -inch below the existing shell thickness without restoring the
On August 5, 1985, the Tank Car Committee met separately with the FRA and
GATX to discuss this modification of tanks with the noncomplying anti-shift brackets. At
his meeting, GATX advised the Tank Car Committee that it already had used the surface
grinding method on 4,350 tank cars and that its removal of 1/16-inch shell thickness below
that required by specifications without restoration had not comprised the safety of the
tank cars. At this time, the Tank Car Committee advised GATX to resubmit its latest
proposal, which included the repair by surface grinding, but to amend it by providing
documentation and justification for use of this method.
During its meeting with the FRA, the Tank Car Committee discussed a number of
issues, including GATX grinding-only repair method, the AAR tank car repair
specification pertaining to actions to be taken after removal of fractures, minimum tank
car shell thickness, concerns that other tank cars approved by the AAR also may not
comply with DOT regulations, the sampling of Tank Car Committee documents,
implementation by the AAR of routine tank car builder site inspections, and improving
communications between the AAR and the FRA.
On August 6, 1985, GATX revised its latest proposal as directed by the Tank Car
Committee and resubmitted it to the AAR for approval. On August 23, 1985, the Tank
Car Committee did not approve the GATX application. Rather, the chairman of the Tank
Car Committee requested clarification of certain aspects of the proposal which GATX
In an August 12, 1985, letter to the FRA's Associate Administrator for Safety, the
AAR said of the AAR/FRA special meeting, "In principle there was no reason to
disapprove the grinding-only method of repair for cracks 1/16 inch or less in depth and
6 inches or less in length." In addition, the AAR stated, ". . . [the] minimum tank car
shell thicknesses specified in Part 179 of 49 C.F.R. apply only to new tank cars," and that
the "combination of the specification for new cars and that for repair relies on the
stipulation of sufficient margins of surplus thickness in the new car specification to allow
for normal repair and deterioration over the life of tank cars." The AAR letter further
stated, "This method, concentrating on conservative standards for new tank cars to ensure
safety over the entire life cycle has proven to be extremely successful in practice — as
witnessed by the highly satisfactory performance record," and ". . . despite the GATX
incident, the Committee is performing its function ably and with great success in ensuring
that rail remains the safest mode for transport of hazardous materials. No
overall shortcomings in procedures or expertise are evident." Concerning improved
relations with the FRA, the AAR letter stated, "The Committee fully endorsed an
expanded scope of two way communications between the AAR Tank Car Committee and
the DOT representatives" and ". . . [it] hopes that the communicative relationship can be
formulated to become increasingly less 'reactive' and more constructively 'anticipative.' "
The AAR suggested the following for FRA's consideration:
At the planning level set an AAR/DOT rail hazardous material
transportation overview group to periodically look "down stream" to
anticipate future regulation problems and/or safety improvement needs.
(The idea is to structure the communications system to stay ahead of
continuous "band-aid" type responses.)
At the day-to-day working level, establish a procedure whereby DOT
would be provided with an excerpt summary of the agenda of regular
AAR Tank Car Committee meetings and upon notification from DOT of
interest, schedule a liaison briefir^ of respective representatives.
With the assurance of strict confidentiality for proprietary information,
add DOT personnel to the mailing list of letter ballots including
approvals of applications of tank car builders so that DOT objections
and/or comments could be registered as part of regular approval process.
Schedule AAR/FRA staff briefings and technical exchanges to explore
current concerns and/or recommendations of the concerned parties.
On August 12, 1985, the FRA advised the Safety Board that it was monitoring the
retrofit programs at approximately 50 AAR-certified shops to ensure that repairs being
performed were in compliance with the DOT and AAR requirements. In its September 4,
1985, report on the December 31, 1984, incident at North Little Rock, Arkansas, the
Safety Board stated:
While its prompt action to remove these tank cars from service is
commendable, the FRA has yet to address the adequacy of the method of
repair for these tank cars as proposed by GATX and approved by the
AAR, and it is not monitoring the adequacy of field repairs made of
these tank cars. The State of Louisiana furnished information to the
Safety Board based on its inspection of field modifications being made to
replace noncomplying anti-shift anchor attachments. The inspections
indicate that the procedure being used for retrofitting these tank cars
may destroy the integrity of the tank shell. For example, heat and /or
mechanical damage may occur to the tank shell during removal of the
existing anchor with a cutting torch or hammer. Also, the tank shell
thickness may be reduced to less than that required by the DOT tank car
specification as a result of grinding out surface cracks. Because more
than 280 tank cars per week are being inspected, retrofitted, and
returned to service using the AAR-approved method, the Safety Board
urges the FRA to institute, without further delay, the action earlier
called for in Safety Recommendation R-85-60.
On August 30, 1985, the Tank Car Committee approved GATX's application
including the use of surface grinding to remove the partial-depth cracks; however, it
conditioned the approval by stating that it could not be used as a "precedent" in support of
future applications. In approving this latest application, the Tank Car Committee stated
"that the repaired area was neither in or adjacent to any high stress area, residual stresses
due to welding were avoided, and the stress concentration due to blended grinding was
low." In response to the AAR action, GATX pointed out that because the AAR approval
was not for precedent use, GATX now had authority to modify only the four cars listed in
the application, and it was precluded from the use of this application in making
modifications to other cars with similar deficiencies.
At its annual meeting on October 17, 1985, the Tank Car Committee discussed the
problem raised by GATX and it was agreed to remove the "precedent" restriction for the
application to allow all tanks with similar deficiencies to be repaired under this
application; however, it stated that any future use of the surface grinding method would
not be allowed unless approved by the Tank Car Committee on separate applications.
A DOT task force reviewed, in part as a result of deficiencies identified with
RAIX 7033, the FRA programs related to the safety of tank cars. In its October 1985
"Report of the Safety Review Task Force on Federal Railroad Administration Safety
Programs," DOT noted that the task force met with the FRA to discuss various
alternatives for achieving greater FRA involvement in the design and construction of new
tank cars and for developing comprehensive inspection procedures for existing tank cars.
The report noted that neither the FRA nor the AAR had a provision for monitoring
construction of new tank cars to ensure that they conform to the approved design and that
as a result, FRA will or has, initiated closer liaison with the AAR Tank Car Committee;
procedures assuring improved oversight and inspection of rail tank car construction; and
procedures for spot checking existing rail cars. The task force recommended:
That FRA, in cooperation with RSPA, establish a closer liaison with the
AAR Tank Car Committee during the rail tank car approval and design
process; develop procedures to assure improved oversight of rail tank car
construction and study the feasibility of adopting construction inspection
requirements called for in DOT's issued NPRM HM-183 and HM-183A,
Requirements for Cargo Tanks Used for Highway Transportation of
Hazardous Materials, and establish procedures for spot checking existing
rail tank cars to assure to proper construction.
On November 22, 1985, the AAR petitioned the DOT to adopt appendix R as
contained in the 1985 Edition of AAR's Specifications for Tank Cars M1002. On June 3,
1986, the DOT published a rulemaking notice (HM-166U) stating its intention to adopt
AAR's 1985 appendix R. With minor changes (not related to M1002), this rulemaking was
published as a final rule on April 19, 1987.
An August 27, 1986, letter from the FRA chief counsel to the AAR noted that
recent tank car issues, notably GATX anti-shift anchor matter, have risen involving the
role of the Tank Car Committee, the application of the AAR specifications for tank cars,
and the DOT hazardous materials regulations. Specifically, the letter stated.
The FRA could not accede to the AAR's conclusion stated in your
[AAR's] letter of August 12, 1985, ... that the minimum shell
thicknesses as specified in Part 179 apply only to new tank
cars, . . . [ that] any deviation from the specifications lacking such
approval by DOT violates the hazardous materials
regulations, . . . [ that] one cannot seriously suggest that a safety
feature required in Part 179 could be modified or eliminated with
impunity once a certificate of construction has been executed. Neither
safety nor logic would countenance such a view. The hazardous
materials regulations do not.
Because of the implications about minimum shell thickness raised by the surface
grinding method proposed by GATX and because of differences between the AAR and the
FRA over interpretations of the DOT regulations concerning minimum shell thicknesses,
both the AAR and the DOT implemented research programs to determine the effects of
the grinding of fractures and to investigate the effect of reducing the minimum tank
thicknesses on the effective service life of a tank car. Additionally, the FRA has stated
that it will issue rulemaking proposals in late 1987 concerning minimum shell thickness
and concerning nondestructive testing. During the April 9, 1987, meeting with the Safety
Board, the AAR representative stated:
. . . that the DOT regulations specify minimum shell thicknesses. The
DOT specifies a 7/16-inch shell thickness as the minimum allowable for
RAIX 7033. Until recently, there has been no indications that shell
thickness was a regulatory or enforcement issue. The AAR Tank Car
Committee had not previously considered the surface grinding technique
as an option for repairing tank cars. The after-the-fact interpretation
questions currently on the table between the AAR and the FRA are in
the process of being resolved. As always. Tank Car Committee
procedures will be altered to agree with the latest decisions.
Also at the April 9, 1987, meeting, the FRA representative stated that the shell
thicknesses prescribed by the DOT regulations was the minimum allowable and that the
DOT regulations do not provide for reducing the stated thicknesses.
Initial Response Actions . — Immediately following a railroad accident, the conductor
is responsible for providing emergency response personnel information about the train and
its contents. When a derailment occurs involving crewmembers in the locomotive and a
caboose, a crewmember from both the front and rear of the train inspect the train
concurrently by walking toward the derailment to identify the last standing cars at each
end of the derailment. This information and the train papers help to identify the cars
involved in the derailment and save valuable time in identifying the location of the
hazardous materials tank cars.
In the accident at Miamisburg, Ohio, all the train crewmembers were located in the
locomotive because the train used a rear-end marker rather than a caboose.
Consequently, the crewmembers were isolated from the rear of the train by the river and
the derailed cars on the bridge. The conductor initially searched the forward portion of
the train for the two "Dangerous" tank cars, but he took no action to dispatch one of the
other crewmembers to the rear of the train to determine which cars remained upright and
on the rails. As a result, the conductor was able to give emergency response personnel
only limited information on the number of cars derailed and the materials involved in the
derailment. The firechief, therefore, had to send firefighters into the derailment site in
full protective equipment to obtain the needed additional information. With this
information and the assistance of the trainmaster, the conductor identified the
phosphorus, sulfur, and tallow tank cars that were derailed on the bridge.
Additional delays were experienced in providing emergency response personnel
information about hazardous materials transported by the train because of other
ineffective actions by the conductor. When the firechief requested all information
carried on the train, the conductor lost valuable time retrieving waybills and reassembling
the waybills in proper order to identify all the cars in the derailment. Additionally, the
conductor inadvertently left an emergency guide for handling phosphorus on the floor of
the locomotive when he searched for the "Dangerous" tank car information. This
emergency guide prominently displayed the shipper's 24-hour emergency telephone
number, information on product hazards, and technical advice of handling emergencies
involving phosphorus that could have aided emergency responders.
In a review of recent rear-end train collisions, the Safety Board noted that in the
event of either a front-end or rear-end collision of a cabooseless train, the consist list of
materials carried on trains could be destroyed and the local emergency response personnel
would be without a critical immediate reference. The Safety Board observed that a
conspicuous consist list container at, on, or near the end-of-train device on a cabooseless
train would help to correct this deficiency. Such a container could be no more than a
large plastic yellow envelope secured to the end-of-train device with wire ties and
lettered "CONSIST LIST" or "HAZARDOUS MATERIALS LIST." As a result of this
review, on June 25, 1987, the Safety Board recommended to RSPA:
Require that on cabooseless trains involving hazardous materials a
conspicuous weatherproof container be affixed at, on, or near the rear-
end marker to hold a current consist list for use by emergency response
On July 31, 1987, RSPA responded that it does not plan to require such a container
for hazardous materials consist lists and that in their view the possibility exists that cars
may be added or removed from a train and that, consequently, the consist may not reflect
accurately the location of hazardous materials cars within a train. In its
September 10, 1987, letter to RSPA, the Safety Board responded that it considers that the
benefits of having information about the hazardous materials in both ends of the train far
outweigh any shortcomings. Further, the Safety Board added that RSPA has ignored
certain factors and scenarios that should be taken into consideration that support
implementation of this recommendation. The Safety Board urged RSPA to reconsider its
position in regard to having a consist list at both ends of the train.
As demonstrated in the train crewmembers' response to the Miamisburg accident,
cabooseless trains can create problems for crewmembers in identifying the derailed cars
because crewmembers are no longer located at both ends of the train. The railroad
industry and the FRA must compensate for this operational change by developing
procedures for cabooseless train operations so that emergency response personnel can be
provided early reliable information about the train consist. Improved methods or
procedures must be developed to assist crewmembers in gathering essential information
and to prevent delays in identifying the cars and materials in the derailment. In addition,
information on the contents of the train should be kept at both ends of the train to avoid
the destruction of all train documents in a derailment or collision. The Safety Board
encourages the railroad industry and FRA to examine the operating practices for
cabooseless trains carrying hazardous materials and to develop procedures and practices
capable of providing reliable, timely information to emergency response personnel about
the presence of hazardous materials in derailments.
The lack of information regarding the location of the sulfur tank car and the
conflicting technical advice provided on the use of water in handling the emergency made
the job of the firechief more difficult. Although the conductor stated that there were
three tank cars in the derailment, this information was not properly verified. Later the
fire chief was advised that only two tank cars were involved in the derailment, and
emergency response actions were disrupted to allow a proper accounting of cars and
materials involved in the emergency. TTiis lack of verified information coupled with the
previous inappropriate trainmaster's communications challenging the firechief 's authority
initially lessened the overall effectiveness of the railroad personnel in working to support
the local emergency response agencies. While these actions ultimately did not have a
significant adverse effect on public safety, railroad personnel must work with emergency
response agencies during emergencies that threaten the public and effectively use their
experience and training to provide accurate, timely information needed by local response
agencies in developing response actions to protect the public.
The initial order of the firechief that the city should begin an evacuation was based
on his observation of the direction and size of the smoke plume coming from the fire area
and his concern about the possibility of toxic pollutants. The presence of toxic pollutants
was later verified by air monitoring data and the large number of medical complaints
during the incident. Furthermore, his initial decision to use a direct hose stream attack
to flood the fire area was based on his review of available technical resource
documentation and advice from available on-scene technical expertise. These initial
actions provided time to assess the situation and safely complete the evacuation, to
establish emergency resource support capabilities, and to coordinate necessary assistance
and technical support.
Longer-Term Actions . — The response actions, which were selected during the next
several days by the city from the many recommended actions by various participating
agencies and organizations, may have prolonged the duration of the emergency and
resulted in a larger evacuation area. However, the selected response actions were
predicated on the limitations of available firefighting equipment, on concerns for the
firefighters safety, on the weather conditions, and on achieving maximum public safety as
opposed to concerns about the operational inconvenience of the railroad and others.
Miamisburg officials recognized that because of weather conditions and equipment
limitations, many of the ideal options for handling the emergency were not possible.
While early actions to accelerate the rate at which the phosphorus was being burned and
applying water spary to the plume of smoke could have significantly reduced the area
threatened by the toxic effluents, this option was not possible early in the emergency or
until the fire was under control.
The Miamisburg officials took early command of the emergency and implemented
effective management procedures for obtaining and using all available technical
assistance. The overall coordination among the many responding agencies was effectively
managed during this 5-day emergency. Communications among the many area response
agencies were well managed, and the high level of preparedness was reflected by the
actions taken during this emergency. The high level of preparedness greatly assisted local
response agencies in effectively recognizing and dealing with inconsistent information
that was provided following the derailment.
The problems which resulted because sulfur was involved raised additional concerns
for Miamisburg officials primarily because of sulfur mixing with phosphorus. Molten
sulfur is presently not regulated as a hazardous material for rail transportation. '^ "
Safety Board believes it should be fully regulated for the following reasons: (1) it can
pose thermal hazards due to its molten state when transported in tank cars; (2) it can
produce toxic pollutants when burned; (3) it can react with other materials and thereby
increase the hazards posed during emergencies; (4) it can intensify fires occurring during
derailments by increasing the total amount of materials subject to burning; and (5) it is
not required to be identified as a hazardous material in the waybills, and information
about its presence may not be provided by railroad personnel to emergency response
agencies following a derailment.
The DOT needs to evaluate the events at the Miamisburg accident regarding the
involvement of molten sulfur. This nonregulated material increased the size of the spill
area, heightened concerns for public safety because of its potential for reacting with the
phosphorus, and increased the amount and the types of toxic pollutants emitted. The DOT
is urged to expedite the issuance of a final rule on Docket No. HM-198 regulating molten
sulfur as a hazardous material to insure adequate safeguards in transportation.
Emergency Response Guides
In its February 26, 1981, special investigation report, 36/ the Safety Board
concluded that the guidance and technical advice provided during an April 3, 1980,
hazardous materials emergency response at Somerville, Massachusetts, impeded the
efforts of local officials to control the spill and increased the adverse effects of the spill
on the community.
The Safety Board further found that the local officials were forced to use a "trial-
and-error" procedure during the emergency because available emergency response guides
and on-scene technical advice were inadequate, inconsistent, and confusing. These
findings resulted in the Safety Board issuing a recommendation to the DOT:
Investigate the adequacy and consistency of hazardous materials
emergency guides and other advice available to local officials for use in
controlling hazardous materials releases furing transportation, and take
necessary steps to assure that they provide sufficient and consistent
guidance and advice to help local officials control hazardous materials
spills quickly and effectively.
In its December 4, 1981, response, the DOT advised it had formed an ad hoc group
composed of representatives from governments, industry, and private consultants to
review the adequacy of the information contained in the DOT Emergency Response
Guidebook and to review the guidance provided in emergency response guidebooks
available from the B of E and the NFPA. The DOT believed that these actions would lead
to guidebook consistency and accuracy. In 1984, the DOT issued a new edition of its
Emergency Response Guidebook.
On April 26, 1982, the Safety Board advised the DOT that it had classified Safety
Recommendation 1-81-1 as "Open-Acceptable Action" and requested that the DOT provide
quarterly reports on the progress being made by the DOT review group. The Safety
Board's letter also noted that the DOT response had not addressed Safety
Recommendation 1-81-2 that called for improvements in the DOT guidance provided on
36/ For more detailed information, read Special Investigation Report~"Phosphorus
Trichloride Release in Boston and Maine Yard 8 During Switching Operations, Somerville,
Massachusetts, April 3, 1980," (NTSB-HZM-81-1).
the use of water in handling phosphorus trichloride. Although the DOT had not
specifically addressed this safety recommendation, the Safety Board advised that it would
hold this safety recommendation in an "Open — Acceptable Action" status until the DOT
issued its 1984 edition of the DOT Guide.
On July 6, 1982, the DOT advised the Safety Board the DOT review group did not
have a fixed schedule for meeting, but it can be convened at the urging of State and local
government, the industry, or the Safety Board. The DOT stated that the Safety ""oard
would be informed of each meeting as it is called and has a standing invitation to attend.
The DOT believed that this approach would be more productive than the issuance of
quarterly reports. The Safety Board was advised that the revision of the 1980 Guide was
being conducted by Johns Hopkins Applied Physics Laboratory and that the B of E and the
NFPA guides specifically were being reviewed. The DOT believed that this action would
lead to guidebook consistency and accuracy. Concerning Safety Recommendation 1-81-2,
the DOT advised that the review group was considering changes to the guidance provided
for handling phosphorus trichloride and that the 1984 Guide would clarify the current
language. On August 11, 1982, the Safety Board advised the DOT that Safety
Recommendations 1-81-1 and 1-81-2 would be classified as "Open — Acceptable Action." In
1984 the DOT issued its revised guidebook. Based on the Safety Board's review of the
guidance provided for phosphorus trichloride, it classified Safety Recommendation 1-81-2
as "Closed — Aceptable Action."
After its review of the response information provided in guides used or available for
the Miamisburg emergency, the Safety Board remains concerned about the adequacy and
consistency of information provided in emergency response guides published by the DOT
and others. Despite the useful amount of information included in the available emergency
response guides, the specific conditions for the recommended actions were not clearly
stated in each case. For example, the term "flooding amounts of water" used in the
guides did not have consistent meaning for either railroad personnel or the firefighters
resulting in confusion as to the appropriate action to be taken. The railroad emergency
specialist, who had had a similar experience, recognized that the objective for using
flooding quantities of water was to cover the phosphorus surface to prevent contact with
the air and that the flooding should be accomplished in the tank car. Other personnel
interpreted the objective as flooding the area of the fire with as much water as possible.
Another inconsistency noted among the available guides was that some guides provided
information on the possibility of an explosion if the phosphorus combined with the sulphur,
while other guides provided no such warnings. Also, none of the guides noted that the
combination of phosphorus and sulphur could result in the emission of more highly toxic
effluents than would either material by itself.
Emergency response guides should state objectives for recommended actions, clearly
define terms that may cause confusion to the various users, and provide essential
information concerning potential adverse chemical interactions. The Safety Board does
not believe that the DOT has accomplished the improvements sought by Safety
Recommendation 1-81-1 and that it should intensify efforts for coordinating with other
developers of emergency response guides. Thus, the Safety Board has classified Safety
Recommendation 1-81-1 as "Open — Unacceptable Action."
Tank Car Performance
The Safety Board has issued many recommendations to the FRA and others for
improving the crashworthiness of tank cars. (See appendix C.) Since 1979, the Safety
Board has directed much of its effort for improving tank car crashworthiness to bring
about new designs to prevent the release of hazardous materials from tank ears.
Tank Car Coupler and Thermal Insulation Performance .— The phosphorus, sulfur, and
tallow tank cars sustained severe mechanical damage during the derailment. The top- and
bottom-shelf couplers on the phosphorus tank car absorbed the initial buff forces during
the derailment. However, the leading head on the sulfur tank car received at least two
slits when it detrucked and struck derailing equipment. Even though coupler separation
occurred between the sulfur and its trailing car, the outer jacket and insulation absorbed
much of the impact forces. Following the derailment, the sulfur tank car was also
subjected to intense heat from the adjacent burning phosphorus tank car as evidenced by
the extent of fire damage to the steel jacket and thermal insulation on the south end of
the sulfur tank car. During this time, the insulation reduced immediate overheating and
allowed the firefighters additional time to cool the tank car.
The lead end of the tallow tank car struck the trailing end of the sulfur tank car
following coupler disengagement during the initial run-in. Both of these ends received
punctures directly above the sills which caused an immediate release of the products. The
sulfur car was equipped with F couplers and the tallow car was equipped with E top- and
bottom-shelf couplers. The couplers of these cars were not restrained during the
derailment and were not totally effective in preventing car misalignment. Had both cars
been equipped with shelf couplers, most likely the head damages would have been
minimized and the total quantity of sulfur and tallow released would have been greatly
During the Safety Board's investigation of the Pine Bluff, Arkansas, accident 37/ on
June 9, 1985, it discovered that the general use of shelf couplers on all types of rail cars
would prevent derailment damages caused by failed coupler connections and would
probably reduce the adverse effects of all train derailments. In response to Safety Board
Safety Recommendation R-86-43, the AAR initiated interchange rule changes to promote
use of the bottom-shelf coupler design on all types of rail cars. In its June 16, 1987,
letter to the AAR, the Safety Board responded that it considers these rule revisions which
facilitate the substitution of bottom-shelf couplers for E-type couplers an acceptable
alternative to the requirement outlined in the recommendation.
Tank Car Attachment Performance .— The phosphorus tank car, which was equipped
with airbrake attachments welded directly to the tank, detrucked on the bridge. This
allowed the tank car's airbrake equipment, which was closer to the ground than any other
tank car tank appurtenance, to impact with debris and the ground. These impact forces
then were transferred through the airbrake support directly to the tank shell which tore
the tank car open emd thereby release large amounts of phosphorus. The other two tank
cars that derailed had the airbrake equipment attached to the draft sill rather than
directly to the tank. These detrucked without either of them experiencing bottom tears
in the tank shells.
The major breach of the phosphorus tank car through which 75 percent of the liquid
phosphorus was released immediately after the derailment could have been avoided had
airbrake attachments been connected to the draft sills or attached to the tank car by a
properly designed bottom reinforcing pad. In addition, had the airbrake support been
designed to break away before allowing the transfer of forces that tore the tank shell, this
bottom breach in the tank likely would not have occurred.
37/ For more detailed information, read Railroad Accident Report— "Derailment of St.
Louis Southwestern Railway Company (Cotton Belt) Freight Train Extra 4835 North and
Release of Hazardous Materials Near Pine Bluff, Arkansas, June 9, 1985,"
The AAR previously recognized the hazards posed to tank cars during derailments by
bottom fittings and attachments. The Safety Board is pleased that the AAR now has
required that all tank cars in hazardous materials service equipped with brake support
attachments welded directly to tank shells be retrofitted by 1992. During this 5-year
period, tank cars transporting the higher hazard commodities are being retrofitted first.
However, in the AAR's decision in 1977 not to include protection for bottom attachments
in its bottom outlet protection program, the AAR missed an early opportunity to address
this safety problem as it was aware that such attachments could rupture tanks during
derailments just as bottom outlets. Had the AAR reviewed the circumstances of the
previous recorded failures, perhaps it would not have discounted the need to protect these
attachments. Additionally, the FRA had no part in this decision not to include protection
for bottom attachments since it was not determining the adequacy of actions taken by the
AAR or determining their affect on public safety.
When the need for reinforcing pads was first recognized by the AAR in 1971, no
design engineering evaluation was made to determine the adequacy of this proposed
modification to tank cars. The initially required 1/4 inch pad thickness was determined to
be inadequate only after fatigue failure separations began occurring during normal
operating conditions. Even after the AAR learned that its requirements for pad designs
were deficient, it did not inform the FRA that the the Federal standard was deficient.
Rather, it depended on tank car manufacturers to voluntarily install thicker pads.
Other investigations by the Safety Board and by the CTC have raised concerns about
the effect on tank car crash worthiness due to attachment designs, materials, and quality
control used in making welded attachments to tank cars. On April 4, 1985, a leaking
anhydrous ammonia tank car was discovered at the Burlington Northern Railroad Balmer
Yard in Seattle, Washington. Inspection of the tank head by the Safety Board determined
that a brittle fracture had developed in an area adjacent to the reinforcing pad.
Metallurgical tests determined that the fracture resulted from the quality of the fillet
weld at the stub-sill to reinforcing pad connection and the low temperature brittle
properties of the steel used for the pad and tank head. Following this incident, the tank
car manufacturer identified reinforcing pad cracks in at least 28 similarly manufactured
tank cars and replaced the reinforcing pads with a fine-grain steel which had improved
low temperature brittle properties. Additionally, the car company equipped several
hundreds of its cars with 9- by 13-inch removable plates on the jackets to facilitate
periodic inspections of the welds on the reinforcing pads during the service life of the
tank cars. All remedial action has been left to the tank car manufacturer with the FRA
and AAR collecting data on the operating experience to determine if additional action is
On January 4, 1986, a sulfuric acid tank car was discovered leaking in the Canadian
National Yard in Cambellton, New Brunswick, Canada. The tank shell, made from steel
displaying low temperature brittle properties, developed a brittle fracture in an area
adjacent to the reinforcing pad resulting in the leak. Of concern was the quality of the
fillet weld at the stub-sill to reinforing pad connection and the low temperature brittle
properties of the steel from which the pad and tank head were made. The investigation
conducted by CTC concluded that ASTM 515 steel, as presently permitted in its and the
FRA regulations, is not an adequate material for the manufacture of tank cars. Further,
the CTC revised its "Regulation for the Transportations of Dangerous Commodities by
Rail" to require the use of ASTM 516 steel for newly built tank cars used or manufactured
The Safety Board is concerned about the longer term implications of these findings
to other tank car manufacturers who may be using similar procedures and materials.
Consequently, the FRA and the AAR are urged to implement an overall assessment of the
problems being experienced with attachments to tank cars and to determine the adequacy
of the design, quality control standards, and practices to identify improvements necessary
in existing design and manufacturing standards and to develop and implement necessary
modifications for existing tank cars.
Tank Car Safety Prc^rams
After this review of the FRA, AAR, and the CTC processes for developing tank car
safety standards and for identifying deficient conditions and acting to remedy those
conditions, it is clear to the Safety Board that voluntary industry actions, rather than
FRA actions, have had the most effect on the safety standards of tank cars. This is a
result of delegating this responsibility to the AAR. In so doing, the FRA and the CTC
have failed to established any substantive control over the AAR's implementation of the
delegated authorities, have not established substantive reporting requirements concerning
actions taken by the AAR, and have not established or implemented a comprehensive
program for periodically monitoring the actions taken on behalf of the respective
Before the FRA was responsible for public safety with respect to transporting
hazardous materials by tank car, the AAR had established procedures for developing
design standards and for controlling the safety of tank cars. When the responsibility for
tank car safety was delegated by the Secretary of Transportation to the FRA or during
the 20 years after, the FRA did not objectively act to assess the adequacy of the AAR's
implementations of a major safety regulatory program. Had it done so, the FRA would
have learned that the AAR had knowledge of many tank car deficiencies and had not
informed the FRA. The FRA would also have discovered that the Tank Car Committee
provided a great opportunity for members representing chemical manufacturers and tank
car owners to control many key decisions affecting transportation safety and provided
little or no opportunity to specifically identify or consider public safety concerns.
The Safety Board notes that voluntary industry efforts taken through the Tank Car
Committee generally have been good and generally have resulted in appropriate action for
improving tank car safety. However, through such control, chemical manufacturers and
tank car owners also are capable of influencing decisions on matters pertaining to safety,
such as tank car retrofits and tank designs, by giving undue consideration to the economic
impact on tank car owners and shippers and thereby adversely impact the safety of
railroad operations and public safety. Even though well intended, the Safety Board does
not agree with the AAR that its industry-oriented membership on the Tank Car
Committee can in all cases give fair representation to public safety concerns.
The removal of full center sills from beneath tank cars and the development of stub-
sill tank cars without appropriate consideration as to the effect of this design change on
the railroads and public safety is a prime example of such influence. The center sill
withstood the buff forces generated during train movements, provided a safe location for
attaching car equipment such as airbrake reservoirs, and provided protection during
derailments for tank discontinuities such as bottom fittings and outlets. Since removal of
the center sill, the investigations of derailments have revealed many needed safety
improvements in the design of stub-sill tank cars for attachment methods and for
protection of bottom discontinuities. Because the FRA took no part in the Tank Car
Committee deliberations on the design of stub-sill cargo tanks and because public
participation in these deliberations was not otherwise achieved decisions were made
without the public safety interests being independently identified and supported.
Had the FRA required the AAR to report any actions taken or to identify specific
tank car failures, the FRA would have been alerted earlier about the numerous and varied
types of attachment failures. These failures were documented by the AAR during
investigations of derailments of stub-sill tank cars and through AAR-required applications
and Report of Repairs, R-1. Further, the FRA should have recognized that the AAR had
not developed and implemented a program for the periodic and thorough analysis of this
failure data in order to identify failure trends among the classes and builders of tank cars.
Earlier recognition of this problem should have induced the FRA to require protection of
all bottom attachments and fittings rather than accepting the retrofit protection program
of the AAR. Had the FRA reviewed the actions taken by the AAR concerning
attachments, it also would have become aware that the present requirement of FRA for
installing pads between attachments and tank shells made in 1971 in response to an AAR
petition was not adequate.
The FRA should have implemented an aggressive program for identifying and
assessing the adequacy of the actions taken by the AAR when it first delegated the
authority for tank car safety. This program could have identified the imbalance on the
Tank Car Committee and then it could have recc^nized the potential adverse effect this
imbalance could have on tank car designs. The FRA easily could have determined that the
engineering expertise for the design of tank cars resided almost exclusively with the RPI
member and some of the trade organizations. Additionally, since the individual railroads
are responsible for the losses which occur during transportation, the FRA should have
questioned how this arrangement could meet the railroad industry's safety needs for the
development of tank car standards much less the needs of public safety.
Thousands of tank cars in violation of FRA specifications were identified as a result
of the Safety Board's investigation of the accident on December 31, 1984, at North Little
Rock, Arkansas; yet the FRA did not take effective action to ensure that proper
corrective actions were taken. If the FRA had been monitoring the AAR actions, it would
have become aware more quickly of the inappropriate actions being taken by GATX and
that these actions were being approved by the Tank Car Committee. Because the FRA
did not monitor the AAR actions, the FRA was not aware that the AAR had approved
GATX's initial application for retrofitting the noncomplying cars in violation of FRA tank
car specifications. Today, the adequacy of the actions approved for retrofitting these
tank cars remains unresolved and awaits the results of research and experience during the
operation of the retrofitted tank cars.
Another issue identified during this review and still requiring resolution by FRA
action was that the regulatory agencies charged with tank car safety responsibilities both
in the United States and in Canada have not formally established procedures for
exchanging information on tank car performance. There are no periodic meetings to
exchange views and concerns about safety improvements for tank cars or to improve the
operations of the AAR under the delegated authorities of both countries. The need for
planned, periodic exchanges of information and views about matters of common concern is
crucial. Since both countries apply the same standards to tank car design and both
countries have delegated responsibilities to the AAR, it would be beneficial and practical
to coordinate efforts.
While the AAR has recently implemented changes in its operations to exert greater
railroad industry influence on decisions made by the Tank Car Committee, to open many
of its records for review by appropriate governmental agencies, and to allow government
regulatory agencies to attend portions of its meetings, the Safety Board does not consider
these actions adequate if the AAR is to meet public safety interests. Using both the
findings from this Safety Board review and from the FRA audit of AAR procedures, the
FRA now must develop regulations and establish program objectives, procedures,
reportir^ requirements, and determine that public safety interests relative to tank car
safety are being adequately served. Among the many actions necessary, the FRA needs to
establish procedures detailing the manner in which the Tank Car Committee must conduct
this delegated public business, the qualifications of persons who serve on the Tank Car
Committee, the mix of interests represented on this committee includir^ the need for
public-at-large members, the types and extent of records that must be maintained, the
requirements for periodic reports to the FRA, the identification of the types of analyses
which must be performed of tank car repair records and the frequency of performing
these analyses, the conditions under which the retrofit of existing cars must be
undertaken, and the provisions for FRA representatives to monitor any and all activities
associated with actions taken by the Tank Car Committee. The FRA should coordinate its
actions with the CTC to take advantage of its experience and concerns and to promote
the development of a single program capable of meeting the safety needs of the United
States and Canada.
As clearly pointed out by the Canadian Royal Commissioner following the CTC
MacMillan Yard Inquiry (see appendix E), public participation in the Tank Car Committee
deliberations affecting public safety is needed. The Safety Board concurs. The FRA
should insure that the public safety needs are identified and supported in all of the FRA
delegations to the AAR. Such an objective would insure that both the safety interest of
the rail industry and the public are met.
1. The lack of early information about the products and numbers of tank cars
involved in the derailment, while not seriously affecting the initial emergency
actions, made it more difficult to coordinate the response activities.
2. Cabooseless train operations require additional procedures to compensate for
this different method of operation in order to provide emergency response
personnel timely and accurate information regarding derailed cars.
3. The emergency response guides used during the accident caused some
confusion because the objectives of the recommended actions were not clearly
stated and some terms were capable of multiple interpretations.
4. Toxic combustion effluents which threatened public safety generated by the
burning phosphorus and sulfur were not recognized by all available emergency
5. While the molten liquid form of the products involved in this derailment served
to facilitate their loading and unloading, its liquid form contributed to the spill
size and amount of product released.
6. When transported by rail, molten sulfur presents unreasonable hazards to
public safety and should be fully regulated as a hazardous material.
7. Local emergency response agencies effectively managed the response to this
emergency and minimized threats to public safety.
8. The bottom rupture and major release of phosphorus occurred as a result of
forces imposed on the tank ear's unprotected brake support attachment and
could have been prevented had the brake equipment been protected against
9. The derailed sulfur and tallow tank cars without their brake support
attachments directly attached to the tank car tanks did not have their tank
shells torn by attachment failures.
10. Industry was aware of the safety problem presented by the brake support
equipment being welded directly to the tank car tank, yet action to correct
this deficiency was not taken until after the accident at Miamisburg.
11. Before the Miamisburg accident, the AAR Tank Car Committee failed to
identify attachments to tank shells on stub-sill tank cars as a significant
12. The performance of the bottom attachment on the phosphorus tank car in this
accident convinced the AAR Tank Car Committee that protective measures
commensurate with the risk posed by hazardous materials transported must
now be provided for existing unprotected tank cars.
13. The shelf couplers installed on tank cars involved in the derailment minimized
the extent of damages to tank heads and maintained the relative positions of
cars in the train during the derailment.
14. A shelf and nonshelf coupler connection does not provide adequate protection
to prevent coupler override and tank head punctures.
15. Steel jacketing on tank cars reduced derailment damages and reduced flame
impingement on the car tank shells.
16. The AAR Tank Car Committee provides the primary control over tank car
safety both in the United States and in Canada because the regulatory
agencies of both countries have delegated their authorities to the AAR.
17. The FRA has not established sufficient direction or controls over the AAR's
implementation of the authority it delegated for tank car safety to assure that
public safety concerns are appropriately balanced against industry economic
18. The absence of effective FRA action for determining the adequacy of the
AAR's implementation of the delegated responsibilities has resulted in an
industry self-regulated system which does not provide adequate public safety
accountability on decisions made affecting tank car designs, construction, and
19. The FRA has not established appropriate reporting requirements under the
authorities delegated to the AAR so that the FRA would have timely
notification of potential tank car safety problems.
20. The FRA and the CTC do not participate in any formal periodic program for
coordination and exchange of information on matters of common interests,
such as, deficiencies in tank car designs and the appropriate use of the AAR in
carrying out authorities delegated to it.
The National Transportation Safety Board determines that the probable cause of the
uncontrollable release of phosphorus was the failure of the unprotected bottom brake
support attachment during the derailment resulting in the tearing of the tank shell.
Contributing to the rupture of the tank was the Federal Railroad Administration's failure
to require retroactively that reinforcement pads be installed between tank shells and
As a result of its investigation of this accident, the National Transportation Safety
Board reiterated Safety Recommendation 1-81-1 to the Department of Transportation:
Investigate the adequacy and consistency of hazardous materials
emergency response guides and other advice available to local officials
for use in controlling hazardous materials releases during transportation,
and take necessary steps to assure that they provide sufficient and
consistent guidance and advice to help local officials control hazardous
materials spills quickly and effectively.
In addition, the Safety Board issued the following recommendations to:
—to the Federal Railroad Administration:
Establish a procedure for evaluating throughout the life of the tank cars,
the performance of all General American Transportation Corporation
tank cars modified to remove the anti-shift bracket welded directly to
the track to facilitate the early detection of any failures that may be
associated with the tank shell thickness having been reduced by the
modification process. (Class II, Priority Action) (R-87-46)
Define explicity those authorities concerning tank car safety delegated
to the Association of American Railroads and establish procedures
governing the implementation of these delegated authorites. (Class II,
Priority Action) (R-87-47)
Require the Association of American Railroads to report on all actions
taken under the authorities delegated for tank car safety. (Class II,
Priority Action) (R-87-48)
Develop and implement a program for effectively reviewing and
evaluating all actions taken by the Association of American Railroads,
tank car repair facilities, and tank car manufacturers under the
authorities delegated to them to determine that all actions comply with
Federal requirements for tank car design, construction, modification,
operation, and repair. (Class II, Priority Action) (R-87-49)
Evaluate annually the Association of American Railroads tank car
specifications to determine that the instructions and guidance provided
on tank car design and construction are consistent with Federal
requirements. (Class II, Priority Action) (R-87-50)
Coordinate a formal arrangement with the Canadian Transport
Commission for routinely exchanging information on the performance of
tank cars, for meeting to discuss common safety concerns related to the
design, manufacture, retrofit, and use of tank cars, and for establishing
controls for and the oversight of the delegated authorities for tank car
safety. (Class II, Priority Action) (R-87-51)
-to the Association of American Railroads:
Determine through analysis of its "Reports of Repairs" records the
causes of tank car attachment failures. (Class II, Priority Action)
Revise present attachment standards for new tank cars and require
appropriate modification of existir^ tank cars based on deficiencies
identified in its analysis of the causes of tank car attachment failures.
(Class II, Priority Action) (R-87-53)
Establish a quality control program that includes on-site inspection to
determine that tank car manufacture, repairs, modifications, and
alterations are performed in compliance with the tank car specifications
approved in applications. (Class II, Priority Action) (R-87-54)
-to CSX Transportation:
Establish crewmember procedures for providing timely, accurate
information to on-scene emergency responders about the types of
hazardous materials being transported in tank cars involved in
derailments where "end-of-train" devices are used. (Class II, Priority
Reemphasize to all operating personnel the importance of directing their
initial activities following a derailment to the cooperative support of
local emergency response agencies. (Class II, Priority Action) (R-87-56)
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
/s/ JIM BURNETT
JOHN K. LAUBER
JOSEPH T. NALL
JAMES L. KOLSTAD
PATRICIA A. GOLDMAN, Vice Chairman, did not participate.
September 29, 1987
The National Transportation Safety Board was notified of this accident at 6:30 p.m.
on July 8, 1986, and immediately dispatched an investigator from the Chicago Field
Office. An invest^ator-in-charge and other members of the investigative team were
subsequently dispatched to the scene from Washington. Individual investigative groups
were established for operations, track, tank car performance, hazardous materials, and
The Safety Board conducted a deposition proceeding as part of its investigation of
this accident on December 17, 1986, at Miamisburg, Ohio. Parties to this proceeding
included the CSX Transportation, City of Miamisburg, Ohio; Albright and Wilson, Inc.,
Association American Railroads, Union Tank Car Corporation, and the Federal Railroad
Washington. D.C. 20594
RAILROAD ACCIDENT/INCIDENT SUMMARY
File Number: DCA 86 HZ 003
Location: Miamisburg, Ohio
Date and Time: July 8, 1986, 4:25 p.m., e.d.t.
Railroad: CSX Transportation
Type of Train: Freight
PersOTis on Board: Four crew members
Type of Occurence: Freight train derailment
Phase of Operation: En route on main track
About 4:25 e.d.t., July 8, 1986, southbound CSX Transportation (formerly Baltimore
Ohio Railroad) freight train Extra 7614 South derailed 15 of the 44 cars in the train. The
train was travelling about 45 mph at the time of the derailment. The derailed cars were
the 24th through the 38th head cars of the train. The train was en route from North
Dayton, Ohio, to Cincinnati, Ohio, with 1 locomotive unit and 44 cars. The train did not
have a caboose. \!
The derailment occurred at the site of a two-span through plate girder bridge about
163 feet in length. The derailed train was the second train to proceed over the track,
after a track surfacing gang worked on the track north and south of the bridge.
The track at the accident location was a tangent single main track, proceeding in a
southerly direction on a descending gradient of about 0.20 percent to the two-span
through plate girder bridge spanning Bear Creek. Past the bridge, the gradient continued
descending in a southerly direction at about 0.06 percent. A sidetrack extended parallel
to the main track for about 3/4 mile on either side of the bridge on the west side of the
main track. The main track was constructed of 132 pound RE section continuous welded
rail (CWR), atop 9-inch by 7-inch by 8-foot by 6-inch-treated oak wood crossties, laid in
crushed granite ballast which extended about 18 inches beneath the crossties an(^ 12
inches or more past the ends of the crossties. "Hie width of the ballast shoulder section
decreased near the north end of the bridge. The spiking pattern consisted of two rail
holding spikes per tieplate, and the rail anchoring pattern was box-anchoring on each
crosstie in the accident vicinity. About 50 percent of the rail anchors were not against
the tie faces in the general area of the derailment.
The bridge consisted of a two-span through plate girder bridge structure of open-
hearth structural steel. The double track bridge rested atop reinforced concrete
backwalls and a center reinforced conrete pier. The spans were 81 feet 6 inches in length.
1/ For more detailed information, read Hazardous Materials Accident
Report — "Hazardous Materials Release Following the Derailment of Baltimore and Ohio
Railroad Company Train No. SLFR, Miamisburg, Ohio, July 8, 1986," (NTSB/HZM-87/01).
53 APPENDIX B
Maximum allowable timetable track speed at the accident site was 50 mph, with a
maximum allowable timetable track speed of 45 mph beginning 0.20 mile south of the
bridge. The bridge was located at milepost 49.7. According to the FRA Track Safety
Standards, the classification of the track was within the parameters of Class 4 track.
Except for the damaged bridge and track structure, the original condition of which could
not be documented, the track met or exceeded the requirements of the FRA's Minimum
Track Safety Standards.
A programmed cyclic track surfacing gang had been raising the track in the vicinty
of the bridge on the day of the accident. The track surfacing gang consisted of a
combination tamper/liner, a ballast regulator, and a backup spot tamper. Manpower
consisted of eight men with the track surfacing gang consisting of the machine operators,
track laborers, and one foreman in-charge. The track surfacing was being performed
out-of-face with a reported maximum raise of 3 inches in one pass. Out-of-face
surfacing was performed north of milepost 49.7 and south of the bridge and was completed
at 2:01 p.m. on July 8, 1986.
The U.S. Weather Bureau's recorded ambient temperatures for the general area on
July 8, 1986, is as follows:
3 00 D.m.
CSX Engineering Department Procedure Bulletin R-39 provides that when the
ambient temperature is expected to exceed 85° F and out-of-face surfacing operations
have been performed at temperatures below 85° F, the imposition of a temporary speed
restriction of 10 mph on the track being surfaced is required during the passing of 12
freight trains subsequent to the surfacing operation. The bulletin also requires the same
10 mph speed restriction to be imposed on the track not dressed or having a substandard
ballast section. The track surfacing operations on the track in question began about
11 a.m. and continued until about 2 p.m.; no slow order was placed on the track after
surfacing operations on July 8, 1986.
Observations made subsequent to the accident indicated that the track structure
immediately north of the bridge shifted laterally. Inspection of the rails and the rail
anchors in the section of track immediately north of the bridge did not indicate any
sudden or recent longitudinal displacement of the anchors relative to the rail. The
maximum lateral displacement of the track structure was measured about 5 inches to the
west at a point about 35 feet to the north of the north backwall of the bridge.
APPENDIX B -54-
Observations of the bridge structure indicated damage from impact with derailed
freight cars as well as substantial thermal damage from a fire subsequent to the
derailment. The north end of the bridge's north span was displaced about 28 inches to the
east. Impact marks were noted on several freight cars which, although derailed,
negotiated passage over the bridge and came to rest south of the bridge structure.
Damage assessments provided by CSX indicate that bridge 49.7 was destroyed in the
accident, as was 457 feet of main track wth additional 1,950 feet of main track damaged
and 500 feet of sidetrack destroyed.
The lateral shift of the track structure immediately north of bridge No. 49.7 is
significant to the events of the derailment sequence. This lateral shift of the track
structure measured a maximum of about 5 inches to the west at a point about 35 feet to
the north of the north back wall of the bridge. It is improbable that this lateral shift of
the track structure could have occurred due to the dynamics of the derailment sequence
itself. The lateral force necessary to accomplish such a displacement typically manifests
itself as rail turned over in the edge of the seat of the tieplates or as rail displaced
laterally from the seat of the tieplate. Further, there were no indications, such as bent-
over track spikes or tieplace displacement to support a theory of lateral track
displacement resulting from the dynamics of the derailment sequence.
The lateral shift of the track structure was also unlikely to have occurred as a result
of thermal stresses. Although thermal damage to the bridge structure was significant, the
rail does not possess the degree of lateral rigidity that would have been necessary to
transmit those stresses laterally and force the entire track structure intact, 5 inches
through the roadbed. Further, the freight cars sitting on the track after the derailment
and through the fire would have significantly arrested lateral shift of the track structure.
The transmission of thermal forces longitudinally through the rails was not possible in this
particular situation since the rails were not restrained on the bridge structure itself
during the fire. Expansion of the unrestrained rails from the fire's heat could not have
been transmitted through the restrained rails in the ballast roadbed.
Although the ballast shoulders surrounding the track structure north of bridge No.
49.7 were sufficiently wide, more than half of the depth of the crossties were exposed.
This condition seriously impaired the ability of the ballast shoulder section to resist
lateral forces. The ballast track section had also been disturbed by the out-of-face track
surfacing operation conducted shortly before the derailment. The maximum raise of the
track was reported to have been 3 inches, raised in one pass. The National Transportation
Safety Board believes that it was poor practice not to have imposed a slow order on the
track until the track could have regained stability.
The conditions noted at the accident site and the practice employed in the track
surfacing operation indicate that the 5-inch lateral shifting of the track very likely
occurred during the passage of the freight train, which in turn derailed due to the track
shifting underneath. The dynamic forces imposed by the passing train in combination with
the inadequate condition of the ballast section probably caused the lateral shift of the
track structure. Whether the entire 5 inches of track shift occurred at once or some
minor portion of the track shift was attributable to the derailment sequence or the
thermal stresses could not be determined. See the attached brief of accident for the
Safety Board's determination of probable cause for the derailment discussed in this
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SAFETY BOARD RECOMMENDATIONS
FOR IMPROVEMENT OF HAZARDOUS MATERIALS
OF TANK CAR SAFETY
Since 1968, the Safety Board has made 57 recommendations to DOT and AAR for
improving tank car safety. Those recommendations issued by the Safety Board which are
applicable to tank car safety are listed below by the subject of the recommendation.
R-69-011 Closed— Acceptable Action
R-78-028 Closed— Unacceptable Action
R-79-016 Closed— Acceptable Action
R-80-014 Closed— Acceptable Action
R-69-028 Closed— Acceptable Action
R-72-020 Closed— Acceptable Alt.Action
R-75-016 Closed— Acceptable Alt.Action
R-78-029 Closed— Acceptable Action
R-78-030 Closed— Acceptable Action
R-78-033 Closed— Acceptable Action
R-78-059 Closed— Unacceptable Action
R-79-024 Closed— Acceptable Action
R-80-012 Closed— Acceptable Action
R-80-015 Closed— Unacceptable Action
R-81-074 Closed— No Longer Applicable
R-81-075 Closed— No Longer Applicable
Monitoring Repairs and Retrofitting
R-78-030 Closed— Acceptable Action
R-78-031 Closed— Acceptable Action
R-85-012 Open— Acceptable Action
R-85-023 Closed— Unacceptable Action
R-85-059 Open— Acceptable Action
R-85-060 Open— Unacceptable Action
R-85-099 Open— Acceptable Action
R-85-117 Open— Acceptable Action
R-86-043 Closed— Acceptable Alt.Action
Tank Car Design and Construction
R-69-008 Closed— Acceptable Action
R-69-029 Closed— Acceptable Action
R-71-009 Closed— No Longer Applicable
R-71-010 Closed— No Longer Applicable
R-72-021 Closed— Acceptable Action
R-72-022 Closed— Acceptable Action
R-72-024 Closed— No Longer Aplicable
R-74-031 Closed— Acceptable Action
R-74-033 Closed— Acceptable Action
R-75-016 Closed— Acceptable Alternative Action
R-75-019 Closed— Acceptable Action
R-78-019 Closed— Acceptable Action
R-78-020 Closed— Acceptable Alternate Action
R-78-021 Closed— Acceptable Action
R-78-022 Closed— No Longer Applicable
R-78-058 Closed— Acceptable Action
R-79-023 Closed— Acceptable Alternate Action
R-79-024 Closed— Acceptable Action
R-79-028 Closed— No Longer Applicable
R-79-065 Closed— Acceptable Alternative Action
R-79-066 Closed— Acceptable Action
R-79-067 Closed— Acceptable Alternative Action
1-80-003 Closed— Acceptable Alternative Action
R-80-010 Closed— Acceptable Action
R-80-011 Open— Unacceptable Action
R-80-013 Closed— Acceptable Action
R-80-014 Closed— Acceptable Action
R-80-016 Open— Acceptable Alternative Action
R-85-061 Open— Acceptable Action
R-85-063 Open— Acceptable Action
R-85-064 Open— Acceptable Action
R-85-105 Open— Unacceptable Action
SUMMARY OF FEDERAL RAILROAD ADMINISTRATION
DELEGATION OF AUTHORITY TO ASSOCIATION OF AMERICAN RAILROADS
FOR TANK CAR SAFETY AND
RELATED FRA AND AAR PROCEDURES AND OPERATIONS
L DEPARTMENT OF TRANSPORTATION REGULATORY REQUIREMENTS
Title 49 CFR 179 Subpart A lists the requirements and procedures for securing tank
car approval and changes to tank car specifications. The following requirements are
A. Delegation of Authority
179.3— Delegates to the Secretary, Mechanical Division, AAR, (Secretary)
authority to issue, based on appropriate committee action, approvals for
designs, materials, construction, conversion, and alteration of tank car tanks
when such is compliance with DOT specifications.
B. Certification Requirements
179.1— Provides general requirements for tank cars. Requires that tank cars
must be built to the specifications of 49 CFR Part 179, that cars built to
specifications predating those of the current 49 CFR Part 179 may continue in
use as provided by 49 CFR 173.31, requires persons performing any function
prescribed in 49 CFR Part 179 must do so in compliance with
49 CFR Part 179.
179.5— Requires the party assembling a completed tank car to provide, before
the car is placed into service, a Certificate of Construction (Form AAR 4-2)
to the owner, to the B of E, and the Secretary certifying that the tank,
equipment, and car completed comply with all the requirements of the
specification (Department's). If the tank is of Class 106A, 107 A, or llOA, then
before it is placed in service, then the builder must also provide a Certificate
of Inspector's Report certifying that the tank and appurtenances comply with
all the requirements of the specifications. In addition, CFR 179 incorporates
by reference specific AAR "approved" standards and practices in the AAR
Tank Car Manual since 1982; 1/ however, approval is exercised by AAR based
on current DOT and AAR requirements. The AAR requirements do not
conflict with Federal regulations.
C. R-1 Report of Welded Repairs, Alteration, or Conversion
179.6— Allows repairs or alterations to be made to tank cars by following
procedures of appendix R of AAR Specifications for Tank Cars - 1982 edition
of the Tank Car Manual. AAR approval for specific repairs or alterations is
generally not required if the procedures in Appendix R are followed or if the
repairs or alterations were previously approved for other cars. Repair is
defined to include reconstruction of a tank to its original design, and
alteration means changes in tank or fittings that do not change the
1/ On April 19, 1987, RSPA adopted the 1985 Edition of AAR's Specifications for Tank
-59- APPENDIX D
specification but which do change the Certificate of Construction. Thus, the
discretion is granted to the Tank Car Committee to approve procedures and
materials incident to repairs and alteration as long as they are in compliance
with the applicable specification. Changes to appendix R of the Tank Car
manual in any later edition (after 1982) have not been incorporated by
reference in the DOT regulations, but no changes have been made which
conflict with DOT specifications.
D. DOT Exemptions
179.3— Requires, when in the opinion of the Committee, such tank or
equipment does not comply with DOT regulations and specifications then the
Committee may recommend service trials to determine the merits of a change
in specification. Service trials cannot be conducted unless authorized by the
Department under the terms of "DOT Exemptions."
E. Proposals for Changes to the DOT Specifications
179.4— Delegates to the Secretary, AAR, the responsibility for progressing
proposed changes or additions in the specifications for tanks. Provides for
submission of application to use any specification change proposed but
disallows the construction of any tank to the proposed specification until such
specification is approved or DOT Exemption has been issued.
n. AAR PROCEDURES
The following AAR procedures cover the implementation of the above DOT
A. Tank Car Committee
General Committee .— Under AAR Standard S-046, Section 10.0, Approvals
(M-1002), an item of equipment, practice, design, product, device or facility
has been "approved" by the AAR Mechanical Division when it is found to meet
the applicable standard, alternate standard, or recommended practice. The
General Committee is responsible for the execution of the responsibilities for
the Mechanical Division including the above "approvals."
The Tank Car Committee is a standing committee of the General Committee
and is subject to the rules and guidelines of the General Committee;
specifically under Circular No. D.V. 2077 -Articles of Organization (Revised
1986), the General Committee:
designates the chairman and vice-chairman of the Tank Car
Committee, the term of office is for 2 years;
approves Tank Car Committee membership based on
recommendations from "member roads" and "others" having
responsibility for the design, construction, maintenance of car
APPENDIX D -60-
approves for the Mechanical Division, reports and
recommendations of the Tank Car Committee docket in
accordance with AAR Standard S-050; or
any member of the Mechanical Division or anyone else ("-050) can
request to have a specific matter docketed for consideration by the
Tank Car Committee.
The Executive Director (Assistant Vice President-Mechanical Division) or
delegated representative is responsible for establishing a file and record of all
Tank Car Committee transactions; setting meeting dates for the Tank Car
Committee at least twice a year; and attendir^ the Tank Car Committee
The Secretary-Mechanical Division is required to maintain a complete record
of the transactions of the Tank Car Committee.
B. DOT Procedural Requirements
Under 49 CFR Part 179, DOT requires the following procedures in securing ear
The procedure for tank car approval requires submission in the form prescribed,
including detailed prints, to the Secretary for consideration by Committee on Tank
Cars (Committee) and other appropriate committees. Approval or rejection is based
on committee action to be issued by the Secretary. Applications can be approved
only when, in the opinion of the Committee, such tanks or equipment complies with
DOT regulations and specifications.
When, in the opinion of the Committee, such tanks or equipment do not comply with
DOT regulations and specifications then the Committee may recommend service
trials to determine the merits of a change in specifications. Service trials cannot be
conducted unless authorized by the Department under the terms of DOT
C. AAR Approval Process
Under Section 1.3.6 (M-1002), the Tank Car Committee is authorized to approve the
design and materials for fabrication, alteration, conversion or
design and materials for all valves and fittings on tank cars;
design, materials, and flow capacity ratings of safety devices used
on tank cars; and
revisions or substitutions of any valve or fittings, or the addition of
supplemental valves or fittings to the tank or to those fittings
covered by the certificate.
-61- APPENDIX D
Under Section 1.4 (M-1002), the application for approval (4-2) of designs and
materials must be submitted to the Secretary, Mechanical Division, the B of E, and
the Tank Car Committee, and when required by AAR specification M-lOOOl, to
other appropriate committees for approval of brake systems and car structure. The
RPI representative of the Committee does not receive applications and drawings.
The office of the Secretary may process and approve applications on the behalf of
the Tank Car Committee provided such applications are with precedent in that they
are similar to previously -approved applications; otherwise approval requires Tank
Car Committee ballot by majority vote and no dissenting comments from the
chairman, the B of E, or the Mechanical Division. Comments must state if they are
based on violations of the specifications or represent a hazardous condition.
In securing approval for construction of tank cars, AAR has four requirements of the
applicant. In that the car company must be an AAR certified shop, use only the
AAR approved drawing in building the car, follow the AAR fabrication practices and
inspections , and submit a car certification to the AAR; specifically:
Step #1 . The car company must prove its fitness as an AAR certified
shop. These certification procedures and detailed requirements for AAR
approval of facilities for fabrication, assembly, alteration, conversion,
repair and associated testing of tank car tanks are contained in appendix
B of the AAR Specification M-1002, Specification for Tank Cars.
Step #2 . The car company must secure approval from the AAR that the
car design is in compliance with DOT specs. RSPA delegates to the
Secretary, AAR authority to issue, based on appropriate committee
action, approvals for design, materials, construction, conversion, and
alteration of tank cars when such is in compliance with DOT
specifications. These procedures employed for carrying out the
delegated authority are covered in the tank Car Manual (M-1002) and the
Mechanical Division's Articles of Organization (revised 1986).
Step #3 . The car company must build the car according to the approved
drawings and perform required AAR inspections. The procedures are
listed in the Tank Car Manual.
Step #4 . The car company must finally certify that the car complies with
DOT requirements. The designated car company officer must certify
that the car conforms to all applicable DOT and AAR requirements,
including specifications, regulations. Rules of Interchange and the DOT
Railroad Safety Appliance Standards. In addition, the car company must
place the DOT specification mark on the tank car. The builder must
submit a properly executed certificate of construction certifying that all
functions performed bv the builder complies with the requirements of 49
CFR Part 179.
Procedures for Changes to the Regulations
DOT Procedural Requirements .— 49 CFR 179.4 requires applicant proposing new or
changed specification to furnish information to justify the proposal including
information on the properties of the lading and the method of loading and unloading.
APPENDIX D -62-
The Tank Car Committee shall review at its earliest convenience the proposal. The
Committee shall report its recommendations to the Department. These reports of
recommendations may be submitted to the B of E, AAR, for its recommendation
before action by the Department. The Department shall give due consideration to
the expert opinion obtained in determining what, if any, action to take.
AAR Procedures for Considering Proposals Regarding Standards and Recommended
Practices, Specifications and Rules (Standard S-050)
Proposals may be submitted by a railroad, car builder, component manufacturer,
private car owner or any other person or organization to Director, Technical
Committees, AAR Mechanical Division (Director). Director will review proposal
and assign it to relevant technical committee.
Relevant technical committee or subcommittee thereof will review proposal and as
a part of its considerations may request the proponent to submit additional
information or to appear before committee or subcommittee to explain in detail and
to answer questions not resolved by the written material.
One of two possible actions may be taken by committee. It may reject the proposal
which requires notification to the proponent of the rejection along with a written
explanation addressing matters raised by the proponent. The proponent then is able
to resubmit its proposal with any additional information available for
reconsideration by the committee.
The second action available is to "progress" a proposal. In this event, the technical
committee must publish either in the Mechanical Division Circular Letter or in the
committee's Annual Report its intention to progress the proposal and solicit
comments from interested parties.
Comments to proposals must be considered by the appropriate committee before
taking final action. The final action and an explanation of the action taken must be
published in a Mechanical Division Circular and all commentors must be advised of
the committee's response to comments.
Final actions by committees then must be submitted for approval to either the
membership of the Mechanical Division at the annual meeting or the General
Committee, Mechanical Division, at times between annual meetings. Approval by
majority vote of either group may direct the committee to take final action which
must be submitted for letter ballot vote to the AAR member railroads.
New or amended standards and recommended practices approved as above must be
published in the Manual or Standards and Recommended Practices. New or amended
revision of the Interchange Rules approved as above are referred to the Arbitration
Committee for final action as to which rule, paragraph, and /or subparagraph will be
modified and for development of the exact wording of the modified interchange
The FRA monitors tank car safety in several ways. On a daily basis, FRA field
inspectors monitor selected tank car facilities. In addition, FRA headquarters
reviews accident/incident data and is now attending AAR Tank Car Committee and
AAR Hazardous Materials Steering Committee meetings.
-63- APPENDIX D
AAR monitors tank car safety in several ways. Facilities are inspected for
recertification every 5 years, more often if warranted. AAR inspectors can audit
tank car facilities and the performance of AAR-approved tank car work at any time.
In addition, AAR Hazardous Materials Systems inspectors perform educational
audits of tank car safety at B of E members' plants.
The railroads are constantly monitoring tank car safety in rail transportation and, as
defective cars and components are identified, AAR systems are utilized to define
car populations and to alert the railroads and effect removal of cars with
deficiencies from service.
ASSOCIATION OF AMERICAN RAILROADS RESPONSES TO SELECTED QUESTIONS
The Association of American Railroads (AAR) provided the following in regard to a
Safety Board request for additional information on March 20, 1987. The following
questions along with the AAR responses have been grouped into three major areas
covering: delegations of authority /requirements, procedures, and monitoring.
Department of Transportation Regulatory Requirements
A. Delegation of Authority
1. What individual(s) at the AAR has primary responsibility for tank car safety?
The Assistant Vice President-Mechanical Division. This position has
responsibilities that embrace general hazardous materials transport as
well as all aspects of tank cars.
2. In what other areas in addition to CFR 179.3 is the authority delegated from
DOT to the AAR?
This question certainly can and should be answered by DOT; however, we
can point to delegations in 173.31, 174.8 and numerous delegations in
Part 179. A careful examination of 49 CFR will delineate the specific
3. Under CFR 179.3, is this authority further delegated from the Secretary to
staff, representatives, and/or standing committees in the AAR?
The delegation of authority, in accord with 179.3 is to the Tank Car
Committee, who may seek specific expertise from other AAR technical
4. With whom does the delegation of authority eventually end? What
organizations do these individuals represent? Are the individuals authorized to
vote in behalf of the organizations they represent?
The delegation of authority is to the Tank Car Committee or the Bureau
of Explosives, as indicated by the regulation. The Tank Car Committee
members have direct technical expertise in hazardous materials
transportation and are appointed from candidates recommended by
individual railroads and industry associations. The qualifications of each
representative is separately evaluated and approved by the Mechanical
General Committee. The individuals vote according to the dictates of
the technical expertise that they possess as related to the issues
-65- APPENDIX E
5. Does 49 CFR delegate discretionary authority to the AAR? In what specific
According to Mr. J. M. Mason's letter of August 27, 1986, certain
provisions of Part 179 delegate discretionary authority to the Tank Car
6. In reference to Mr. Mason's letter of August 27, 1986, to Mr. A. Johnston, is
the AAR in agreement with the points raised? Please explain.
The AAR generally agrees with the conclusions of Mr. J. M. Mason's
letter of August 27, 1986. The AAR does not enforce or promulgate
requirements that are in conflict with the regulations.
7. What criteria exists for performing evaluations of the delegated authority and
periodically assessing whether or not the delegation should continue?
Frequency, periodic reporting requirements, at what level?
DOT/FRA exercises oversight consistent with their responsibility. There
is routine interaction between AAR and FRA, including attendance of
FRA personnel at recent Tank Car Committee and Bureau of Explosives
Steering Committee meetings. Circulation of periodic reports of
Mechanical Division activities. Early Warning Letters, and Maintenance
Advisories Letters are regular practices. Also, there are numerous
written inquiries from FRA to AAR concerning condition and status of
rail equipment. Information exchanges and inquiries occur at both
management and working levels. Formal communications are normally
between the Associate Administrator for Safety and the AAR Assistant
Vice President-Mechanical Division.
B. Certification Requirements
1. Under CFR 179.5 why does the B of E get a copy of the application in addition
to the Secretary?
The Bureau of Explosives is copied for coordination purposes. The intent
is to apply the widest possible scope of expertise to the application
2. Car owners are certified according to which edition(s) of the Tank Car
Certification is to the current issue of the Specification for Tank Cars.
It is realized that in some instances there is a time delay in DOT's
incorporation by reference of AAR's current issue; however, past
differences have mainly only been of an administrative nature. The AAR
is not aware of any cases where use of current versions of standards has
resulted in substantive safety and/or regulatory concerns.
C. R-1 Report of Welded Repairs
In reference to Mr. A. Johnston's letter of August 12, 1985, to Mr. J. Walsh, AAR
maintains that "repairs and alterations to tank cars are governed by appendix R of
AAR Specification for Tank Cars pursuant to 49 CFR 179.6 and by 173.31, not by
APPENDIX E -66-
the Part 179 requirements." Please explain the basis for this interpretation. Have
other R-l's been submitted which allowed old cars to be repaired without meeting
Part 179 requirements? If so, under what conditions? If so, number of cars
Rather longstanding past industry practice is not in complete accord with Mr.
J. Mason's letter of August 27, 1986. Clarification is being sought at this
time. We are aware of no R-l's that have been inconsistent with the
regulations and interpretations that were in effect when the forms were
submitted. Where mandated, retrofits have been effected in accord with the
provisions of subsequent rules.
D. DOT Special Permits
1. Are these practices still in effect? When are they employed?
Traditionally, proponents have gone directly to DOT for approval for
deviations from the regulations.
2. In what specific area has the Committee used this delegation? Examples.
The Tank Car Committee has exercised the delegation only to advise
proponents to seek exemption directly from DOT. Service trials which
may be in conflict with the regulations are handled in the same way.
E. AAR Proposals for Changes to DOT Specifications
1. Under Section 2.3 (M1002) car companies must meet the "proposed revisions"
to the specifications regardless if they are adopted or not by DOT. Why is the
AAR seeking DOT's approval? Has DOT previously rejected an AAR proposal
for changes to tank car specifications under Section 2.3?
Section 2.3 of M-1002 is consistent with or exceeds the regulations.
AAR seeks DOT approval and publications to make the regulations as
stringent as need be for maximum safety. Certain AAR proposals have
been rejected and subsequently approved with appropriate modifications.
2. What AAR proposals for regulatory changes have been docketed by the Tank
Car Committee for 1987?
A review of the March 1987 Tank Car Committee agenda shows the
following proposals for regulatory changes:
T76. 16-85 Alternate Gasket Materials
for Liquefied Flammable Gas Service
T73.6-86 Outage Requirements
T79.4-83 Obsolete Specifications
-67- APPENDIX E
T94.14-84 Yield Strength vs. Ultimate
Strength for Shell Thickness
T94. 16-85 Minimum Wall Thickness Requirements
T95.7-81 Use of Steels in Tank Cars
T95.10-82 Alloy Steel Castings
T-75.7-86 Removal of Commodity Stencil From
Cleaned Tank Cars
3. What is the Subcommittee on Specifications?
The Subcommittee on Specifications no longer exists. It was replaced 15
years ago by the members of the Tank Car Committee, functioning as
two subcommittees in considering the proposals that have been
developed by subordinate working groups. Recommendations of the
Subcommittees are further considered by the full committee at its
4. Since the B of E is also part of the AAR, for what reasons would applications
and proposals be referred to the B of E?
See our response to V.B.I.
5. Who in the B of E receives and reviews the above? What are those persons
The properly constituted Steering Committee of the Bureau of
Explosives addresses all referrals. Qualifications of staff personnel are
duly reviewed. The AAR 0-T General Committee approves appointment
of all Steering Committee members based on technical qualifications.
Generally, B of E personnel are qualified over a broad spectrum of
hazardous materials concerns.
6. What records of AAR proposals are kept and to whom are they available?
Under what conditions?
AAR staff supporting the Tank Car Committee and the Bureau of
Explosives Steering Committee maintains lists of present and past
petitions to DOT. These are public documents and are readily available.
A. Tank Car Committee
1. Who may serve on the Committee?
All who are technically qualified and duly appointed under the bylaws
and authority of the AAR Mechanical Division General Committee.
APPENDIX E -68-
2. How is the committee constituted?
The committee is constituted in accord with the referenced bylaws.
Currently there are 16 voting members authorized.
3. What organization does the Chairman of the Tank Car Committee represent?
Ethyl Corporation /CM A?
The chairman of the Tank Car Committee serves the committee to
facilitate its deliberations. The current chairman, who took office in
1985 and will step down in June, 1987 is employed by Ethyl Corporation,
which is a member of CMA.
Provide same information for other members of the committee.
At present there are 10 railroad and 6 non-railroad voting memberships
4. What procedures must the Committee follow in carrying out the delegated
Committee procedures are conducted in accord with Robert Rules of
Order. Agendas are prepared and issued prior to meetings, and minutes
are recorded and kept. Proponents are offered the opportunity to
present evidence at predetermined and dedicated portions of meetings.
Tank Car Committee members who may have a semblance of conflict of
interests on certain dockets are not permitted to be present during
discussion and voting on these subjects.
The Tank Car Manual (M-1002) prescribes procedures to be followed in
considerations of applications for approval of designs and for facility
5. What records of the Committee must be open for public inspection? For FRA
inspection? Other inspections and by what organizations?
Public inspection is available on appropriate request. FRA has availed
itself of the right to audit transactions as deemed necessary. In certain
circumstances legal depositions have been honored.
6. Define the term "majority" as it relates to the number of Committee votes
necessary for approval of an action?
Majority means a plurality of the voting members present, provided that
a prescribed quorum exists. Letter ballots must have a majority of all
eligible voting members.
- Do all members have to vote for an action to receive approval?
It is not necessary for all members to vote for an action to receive
approval. A majority of a quorum is sufficient at meetings.
-69- APPENDIX E
- Is this procedure always followed?
- Do specific interest groups (car manufacturers, railroads, etc.) abstain from
votir^ on certain dockets? Which groups vs. which types of actions? Trends?
Members abstain when there may be a potential conflict of interest or a
direct involvement. Moreover, they absent themselves from all
discussion and voting on such propositions.
7. What special interest balance is required in appointing Committee members?
At the present time the balance prescribed by the Mechanical Division
General Committee is 10 railroad and 6 non-railroad voting members,
with the chairman appointed (and properly approved) from among the
8. How are public safety concerns introduced, supported, and weighed in the final
Both railroads and the non-railroad members have a lot at stake if any
deficiencies in safety occur. Final voting invariably reflects this fact.
The safety performance record of hazardous materials transportation by
rail is the bottom line and is, we believe, extraordinarily commendable.
9. What are the other AAR committees to which applications may be submitted?
All applications are submitted to and final disposition is made by the
Tank Car Committee.
Other AAR committee, such as the Hazardous Materials Systems (BOE)
Steering Committee, the Car Construction Committee and the Wheels,
Axles, Bearings and Lubrication Committee are called upon by the Tank
Car Committee as needed to supply specific expertise to address issues
associated with the safe transportation of hazardous materials by rail.
Recommendations from these committees are considered in the decision
process; however, actions on applications rest solely with the Tank Car
- What are the qualifications of their memberships and their makeup?
Qualifications are based on expertise in the particular technical
discipline needed for the committee. Such qualifications are offered in
writing for each candidate from officers of the sponsoring organization
and are approved by the Mechanical Division General Committee, which
is comprised of the Chief Mechanical Officers of member railroads.
- What procedures must they follow?
The procedures utilized are stipulated in the bylaws of the Mechanical
APPENDIX E -70-
- What weight might they have in approval or rejections?
- What records must be maintained? What records are open to inspection and
by what agencies or entities?
Records are kept, maintained and are available as described in the
response to V.A.5.
B. Procedures for Changes to the Regulations
Under what conditions are AAR proposals for changes to DOT Specifications on tank
cars submitted to the DOT for review? Was the proposal dated 1-23-81 by R. Thelen
(T-94.2-80) submitted to the DOT? If not, why not?
AAR-adopted proposals for changes to DOT specifications for tank cars are
always submitted in petitions to DOT. Mr. Thelen's letter of January 23,
1981, which you have referenced, was not such a proposal.
C. AAR Approval Process
1. Why and how are the AAR's M-1002 standards different from the FRA
Any differences can be attributed to the basic philosophy that the
federal regulations contain the requirements and the AAR ^1-1002
standards specify the methodologies of accomplishment. There are
certain instances where AAR specifications go beyond FRA
requirements. This is because these AAR standards are formulated to
provide additional safety margins and thus can exceed minimum federal
2. How does the AAR see these two standards as different/or similar? Are both
See reply above.
Both are necessary in order to provide details for implementation and to
facilitate sufficient attention before the condition specified in the
federal requirements is reached.
3. Does AAR grant approval of alterations and repairs based on the latest edition
of the Tank Car Manual?
AAR does approve alterations and repairs based on the current issue of
- In this area, were deviations from the DOT specifications allowed?
-71- APPENDIX E
- Were the builders/repairers aware of the difference?
Builders/repairers should be confident that no differences on any
4. Is the GATX anti-shift bracket an example of the above? Specifically what is
the minimum allowable shell thickness permitted by AAR? And DOT? How
has this difference been resolved?
DOT regulations specify shell thickness. Until recently there were no
indications that shell thickness was a regulatory or enforcement issue.
The after-the-fact interpretation questions currently on the table are in
the process of being resolved. As always Tank Car Committee
procedures will be altered to agree with latest decisions.
Are all R-l's used to determine trends or identify critical defects in accident? How
is this assessment made? Please cite a few examples where critical defect in tank
car components have been identified on the basis of R-1 report reviews. Describe
the data storage and retrieval system used?
R-1 forms are reports of repair, alteration or conversions made to tank cars in
accord with previously approved procedures. Patterns of repair vs. operating
experience are often used for correlation purposes. Assessments are made
through analytical comparisons by AAR staff members. One example was in
the detection and isolation of non-pressure stub sill tank car buckling
tendencies, wherein a retrofit modification was imposed.
All tank car attributes are submitted and contained in a file of certificates of
construction. Both manual and automated data processing systems are
available to assist in analysis. A mechanized data base of equipment details
(UMLER) is also regularly utilized.
Does the AAR have a critical defect program for identifying defective tank car
components and advisir^ the industry when a critical defect is identified? What
procedures must be followed?
Defective tank car components are identified and traced chiefly by the "hands
on" experience and monitoring efforts of the railroads who are intimately
involved in the movement of the cars. Appropriate AAR committees
determine severities and recommended remedies to the Tank Car Committee,
depending on the particular nature of the problem.
Established Early Warning and Mechanical Advisory systems are used to alert
railroads and to effect removal of cars with deficiencies from service.
When a problem is identified in a portion of a car owner's fleet, what procedures
does the AAR require the car owner to take in identifying the problem? When is the
When a problem is identified, the car owner, shipper or other involved parties
are requested to furnish supplementary information, and usually is invited to
APPENDIX E -72-
present evidence and answer specific questions posed by the Tank Car
Committee. FRA is notified of all verified significant problems that concern
hazardous materials transportation.
What assurance is there that the problem is restricted only to the group of cars the
manufacturer removed from service?
Appropriate record searches are utilized by AAR to uncover car similarities
and /or past incidences. However, there are other strong reasons why the car
owner or shipper having been notified of a potential problem, responds in a
responsible manner. The owner or shipper recognizes the liability incurred by
knowingly permitting cars with identified problems to continue to operate.
Were the above procedures followed by car companies and AAR following North
Little Rock, Arkansas; Elkhart, Indiana; Seattle, Washington (Richmond Tank Co.);
and Miamisburg, Ohio? Are these actions adequate in identifying permanent
solutions to industry-wide problems? How? Why?
The above procedures have been followed whenever a problem has been
identified. We believe that the resultant AAR actions have generally been
adequate. The tank car safety record is extremely good. Of course there is
always room for improvement, and AAR is evaluating and implementing new
tools and procedures to upgrade effectiveness.
EXCERPTS FROM RELEVANT EMERGENCY GUIDES FOR PHOSPHORUS
DOT Guide #38. 1980
Some of these materials may react violently with water.
Small Fires: Dry chemical, soda ash or lime.
Large Fires: Flood with water.
Do not get water inside container.
Move container from fire area if you can do it without risk.
Cool containers that are exposed to flames with water from the side until well after
fire is out.
For massive fire in cargo area, use unmanned hose holder or monitor nozzles. If this
is impossible, withdraw from area and let fire burn.
DOT Guide #38. 1984
Small Fires: Cover with sand, earth or water spray and keep it wet.
Large Fires: Water spray, or fog.
Do not scatter spilled material with more water than needed for fire control.
Move container from fire area if you can do it without risk.
Cool containers that are exposed to flames with water from the side until well after
fire is out.
For massive fire in cargo area, use unmanned hose holder or monitor nozzles. If this
is impossible, withdraw from area and let fire burn.
AAR/Chessie System Form
Emergency Handling Precaution for Hazardous Commodity 4916141
Phosphorus, White or Yellow, in Water
If material on fire or involved in fire:
Flood with water.
When fire is out, cover all suspected material with wet sand or earth, until material
can be permantely disposed of.
Envirnomental considerations— water spill:
Use natural deep water pockets, excavated lagoons, or sandbag barriers to trap
material at bottom.
Environmental considerations— air spill:
Apply water spray or mist to knock down vapors
Combustion products include corrosive or toxic vapors
APPENDIX F -74-
National Fire Protection Association Guide 49: Phosphorus
Phosphorus, White, or Yellow
Description : Colorless to yellow, translucent, soft waxy solid.
Fire and Explosion Hazards : Unites spontaneously on contact with air at or above 80" F.
Explosive when mixed with oxidizing materials.
Life Hazard : Fumes from burning phsophorus are highly irritating but slightly toxic except
in very high concentrations. Solid yellow phosphorus causes severe burns. Avoid skin or
Personal Proctection : Wear flame-retardant full-protective clothing.
Fire Fighting Phases ; Deluge with water, taking care not to scatter, until fire is
extinguished and phosphorus has solidified, then cover with wet sand or dirt.
Sulfur: when a mixture of sulfur and yelow phosphorus is warmed, the two elements unite
in all proportions with vivid combustion and power explosions.
Ann. Chim. et Phys. (1) 4:1 Ann. Chim. et Phys. (2) 67:332 Comp. Rend. 96:1499, 1771. R.
Bottger, J. Prakt. Chem. (1) 12:357 (1837). See Phosphorus plus Cesium.
CHEMTREC: File Card for Phosphorus
For phosphorus tank car fire:
Cool with water from the side
Use unmanned hose monitors; if unable to withdraw
Do not use high pressure hose stream; use flooding amounts of water spray or fog
Refer to DOT ERG(1984) for guide reference; reactivity: avoid air, organic matter,
peroxides, etc. produces P408
CANADIAN EMERGENCY FORM FOR PHOSPHORUS
V »„. ' ..... _ /^
Under Water UN 1381
Spontaneously combustible 4.2
Immediate Action Information
on other side of this sheet
Phosphorus is a wax-like solid, insoluble in water. It isj
usually shipped under a blanket of water to protect \i
from air. If the phosphorus becomes exposed to air it
spontaneously ignites. Contact with the matenal causes:
s^ere bums It is extremely poisonous by ingestion.
Boiling point: 280 °C
Melting point: 44*C
Igndes spontaneously when dry. Reacts violently with
organic compounds and many other chemicals. Heated
containers may rupture violently. Water is the best fire
fighting agent for large fires On burning, releases dense
irritating white fumes.
Not explosive but, when contained, heating may cause
a violent rupture. Contact with certain reactive materials
may cause an explosion.
Contact with skin or eyes may cause severe burns, j
Irritant fumes are produced during combustion Some ■
effects of inhalation may be delayed for 24 hours, i
Residues from decomposition are corrosive. Highly i
toxic if swallowed. '
Recouvert d'eau UN 1381
Matiere s'enflammant spontanement 4.2
Mesures d'urgence au verso
Le phosphore est une solide cireux, insoluble dans
I'eau. II est normalement expddi^ immerge dans Teau «
pour le prot^ger de I'air. Si le phosphore est expo6^ k ,
I'air il s'enflamme spontanement. Un contact avec ce
produit causera des brOlures s^v^res. II est extr£me-
ment toxique par ingestion.
Point d'^bullition: 280*C
Point de fusion: 44'C
S'enflamme spontanement k Tetat sec. Reagit violem-
ment avec les composes organiques et divers aufres
produits chimiques. Les contenants surchauffes
peuvent se rompre violemment. L'eau est la meilleure
substance pour combattre les incendies majeurs En
brulant, d^gage une fumee blanche dense et imtante.
Le phosphore n'esf pas explosif. Toutefois. lorsqoe
enferme, un nsque d'explosion peut se produire si la
temperature est suffisamment elev^e Le contact avec
certains matenaux reactifs peut provoquer une
Le contact avec la peau ou les yeux peut causer de
severes bnCilures llyadegagementde vapeursimtantes
lors de la combustion. Certains effets de I'mhalation
peuvent Sfre retardes de 24 heures Les residus
provenant de la decomp)osition sont corroafs Forlement
toxique si ingeste.
Wagon .■;Benio.gue CcnieneM ^ ^i.-''Jfj,\i:\-Jr J ff 'tfr^i-, ■' ■■
^^ Emergency Response Form "^■"•^i.-'.'v''-,^
^ SPECIAL COMMUDITYi^i^^s^
^^^ Additional iriforfnation'brv'other sicle"*' ^^'^*'
^ Phosphorus, Yellow,^^
f^ Under Water U 1^1381 ^^l&
'^^ Spontaneously combustible 4,2 j'i- iij^ i v2 '
:■* -.■■ij.v_ -Tt*
mRecxyuvert d'eauUN 1381
f Matiere senflammant spontanement 4.2
ippe^-designated 24-hotMefneiveri(^ leiephbne numbers '^■.■"*.''?^%^^5Tj »
de l6l6phore toofnls oat Texp^diteur en cas tfiwgence [2^ jieures aw 24).
IMMEDIATE ACTION 1>.^;
'General: '^^^^-■^^^f^;^ M^^ M^'^ I
■;Keep )jpwind No unnecessary personnel. Avoid contact with the.7j
^•matenaland inhalation of fumes. Wear (ulf protective clothing and &eW-,>
."";Jor tamed breathfr^g apparatus (SCBAJ, Do nol handle broken packages j
^'.without full protective equipment H safe procedures permit, transport jj
•unbroken containers to_a safe place. Isolate hazardarea" Minimizef
escape of phospnqrus or'of water which has contacted it ''^'r.'^t* -^f
Sp\\\ or l^ak:te.,£^t:J. V^^J:!^^:^ ^
ilhout risk, or cool container]© soJfdify contents Notify J
-Stop leak if
. Ihe shipper immediately that experts are required for^area decoi
■'lamination Build dikes as riecessary and keep spilled material covered
with water, Keep area wet with flooding quantities of water spray. tt-
possible, collect rpn-off water for subsequent recovery. Remove
: clothing suspected of contamination as soon as possible and wast\or'
nerse m water Immediately.
Cover small fires wflh water, sand or earth- For large fire, use a low-
-pressure water spray Use water in flooding guantitjes'as a fog Ifan^
^'engulfing tire tt^reatens but safe orocedure permils.set up unmanned^
; hose streams. Use water to cool containers exposed to fire. ■^,,
Wash material from skin with water Flush eyes ar^d skm burns with low'
pressure water for at least 30 minutes, or cover sKjn burns with wet
dressings soaked in 5% sodium bicarbonate solution for burns!^
swatlowtng or fume exposure, prompt medical attention is essential If^
fumes have caused diffcult breathing, administer oxygea If swallowir>g
of phosphorus or of the blankenmg water is suspected, induce vomiting.
Keep patient at rest, "l^v'-^ * .1^ ' ^S' •"# '.?1^"-;- -"^-^'V*^-'- •■-.''
iester en amont du vent Pas de perso'nnef Inutile.'Eviter tout contact v*
I vec le produit et rinhalatidn des vapeJrs^ Porteruhe teriue Ci&pro-^-_
) ?ction complete et un apparel! respiratoire autojtorne. Ne pas martlpuler^i^
ies emballages abFrn^s saris ^quipement de ^otection complet Si ta'^J-
ecurlt6 le permet. transporter Ies contenants non endommag^s dan**.^
in enOroit sCir Isofer la zone dangereuse. Minimisef r^chappement du;^
thosphore et de Teau qui vest entr^ en'oontact-"^ -£-fcf ^^' J^eTs .
Suppnmez la fuite, s'tl n'y pas de risques ou refroidissez les'contena'nfs '*
ivec de feau pour solidifier son contenu. Demander imm^dialemerU a
'exp^diteur d'envoyer des experts pour netloyer (a zone. Au besoin"
jndigueret garde r le produit recouvert d'eau GarderTa zone moi>in^
wee des quantit^s abondantes d'eau en piute Si possible ramasser'
'eau phosphor^e pour r^utilisalibn, Eniever le plus tftt possible tout
z&lement pouvant avoir 6te contamm^ et laver ou im merger dapsde "^
'eau Dn mediate me nt. ■_' '^ ■^vV""'*^^"' '^^''^r^'^";^'*^ "^
Incendie:'';;;!^?; i'^V-^'^J.V j-jj^;:; ;/?y^^
Pour tes incendies mine'urs, recouvrlr cfea'u, de sable'ou de'fer're.Voui^
Jes incendies maieurs, \jliliser de feau i basse pression sous forme de' 'v
'ui'e. Arroserabonda.mment avec de I'eau en brouillani Si TincendieV"
et installer des boyauxfixes. non f
! I'eau pour,refro'dir Ies contenants";,
iLaver la peau avec de feau pour enlever le pro<3uit. En casdeSrDlure,"^.
rirv^er abondamment Ies yeux ou la partie toucti^e avec de feau fi l^asse Y
Ipression pendant au moins 30 minutes, ou mouillez-les avec un ltnge^
imbib^d'une solution de bicartwnatede soude 5%. Suite auxbrulures. S^"
Tingestion ou A une exposition aux fum^es, des soins rD^dicaux Orients* -
Isont essentiels Si la victime a respir^ deslum^es de I'lncendie/C
administrer-lul de foxy^fene si 'a respiration est difficile, ^rovoquer le*^
^|omissement SI t'on suspecte I'lngestion du pfiosphore ou de feau'
^hoEp^vor6e Garder la^victime au repos_ T[f,«4- j^; /> I'^^l;.^''^.
inenace et que la security le pen
bp^res par du personnel Utiliser de I'eau pour,refroidir
Jexposes au feu. "" - * - -''■ » ^-* ' ^■-- ---* . ^ -.
. Placard Notation. , -'SPONTANEOUSLY COMBUSTIBLE 4"'PLAC|
Mention d'eliquelage PANNEAUX -INFLAMMABLE SPONTAN^ME
•JT - -. ■ - ■ ii--' ■_'.<•( <^'' i't »• •■ 1- • ■■ ■'■-■ s,'- r-r-./i
Shipper: ERCO. a division o( Tenneco Canada Inc. i.-Vj/""^
ExpediieurERCO. une division de Tenneco Canada Inc. ,");''.; J
T 4" APPLIQUES
,'4.i.si-Vv\.\!--'( ■ ,-.«;*-- -A.-' r^i'jn , ., _
estmation. .^^_^j£RNALj) '0^0 U.S. A;
Destination- -' ■' . - . .
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CANADIAN RAILWAYS TRANSPORT COMMITTEE
BOARD OF INQIRY: MACMILLAN YARD ACCIDENT
CTC'S RELATIONSHIP WITH AAR
Prior to CP Rail's accident at Mississauga, with its immediate
holocaust that enveloped most of the 21 tank cars derailed, the prevailing
philosophy of the Canadian Transport Commission in certain critical areas of
expertise was to rely heavily on the Association of American Railroads (the
AAR). Design and specifications of tank cars were considered to be the
province of the competent and knowledgeable Tank Car Connnittee of the AAR.
The assignment of such responsibilities to the jurisdiction of the trade as-
sociation of American railroads was not perceived, at the time, as being in
any way unusual ~ it was, or so it seemed, just being practical.
This ingrained philosophy persisted as tank cars got bigger and
their respective ladings ever more diverse and deadly. The thinking was on a
more positive note in the months leading up to Mississauga but it was not, as
yet, distinguished by involvement and action.
The void did not escape the attention of the Grange Royal Commis-
sion inquiry. The Canadian General Transit Company, pointing to the void,
proposed to the Royal Commission that it be filled in this way:
"A trade association or branch of the CTC ought to be
created to re-evaluate performance standards of all
safety devices and analyze all retrofit proposals on a
cost/benefit/risk basis. This body ought to have the
research capability and liaise with the DOT, FRA (Federal
Railroad Administration), RPI (the Railway Progress
Institute ~ suppliers of equipment to railways), AAR and
appropriate trade associations such as the Chlorine
The Royal Commissioner himself addressed the matter in his report.
Dealing with the CTC Red Book, at page 113 of his report, he stated:
"The difficulty, if there is one, is that it follows
almost inevitably that the initiative in the field lies
with the AAR. While Canadian railways and indeed
Canadian manufacturers and shippers are members or as-
sociate members of that organization there is no
contribution to its deliberations on behalf of the
Later, turning to problems demonstrated at Mississauga with tank
cars, the Royal Commissioner at page 152 of his report, stated:
"These problems are all being worked on but they are not
being worked on in Canada. Their solution seems to be
left to the AAR Tank Car Committee which may perhaps be
affected by the recommendations of the National Transpor-
tation Safety Board. I have no doubt that the Canadian
railways and the Canadian tank and car manufacturing
APPENDIX G -78-
companies and shippers contribute to the AAR delibera-
tions, but it is not in my opinion enough to rely on
private and American efforts. We are concerned with the
transportation of dangerous goods in Canada. We must
take advantage of all knowledge to be obtained from any
source but we must also attack the problems from the
viewpoint of the Canadian public and I am sure there is
in Canada knowledge and talent available to help."
Canadian National Railways, as one of the chief parties to the
inquiry I conducted (the incident having occurred in its yard), addressed the
concerns and opinion that, through the words of Mr. Justice Grange, I
introduced for consideration of the parties. In final argument, CN produced
a succinct statement as to the purpose and functions of the AAR. There seems
to have been little actual evidence about AAR, although there were very many
references to it. I am aware, of course, that my colleagues and the parties
to the inquiry all know the role of AAR. So that the record will be clear in
this report, and as background to the views of parties who responded on this
subject, I avail myself of relevant information about AAR as found in the CN
CN pointed out that the most important role of AAR — an associa-
tion of almost all North American railways ~ involved the setting and
enforcing of rules and standards relating to the interchange of both traffic
and equipment. It provided a forum in which matters of common interest could
be discussed and analyzed. According to CN:
"It is a self-regulating agency which can provide
technical, and other, assistance both to its members and
any other group that requires its expertise. The As-
sociation is interested in safety matters and efficient
and technically correct operation of the railways and its
membership is such that it can draw upon a substantial
body of technical knowledge."
CN emphasized, too, the activity of AAR relating to international
trade and, in consequence, the interchange of equipment back and forth across
the United States-Canadian border:
"It is also important to bear in mind that the AAR
operates in a geographical territory over which no single
regulatory body has complete jurisdiction and, thus, to a
large extent, performs a necessary coordinating
CN stated that "a parallel can be drawn between the AAR in railway
transportation matters and Lloyds of London in maritime shipping matters".
CN also gave me its views on the matter at hand. These are as
-79- APPENDIX G
"Admittedly, the AAR does not possess a status similar to
a regulatory agency but, it is our submission that this
Association is in an excellent position to provide en-
lightened and meaningful advice to regulators and
industries on both sides of the border. For example, the
AAR, working in conjunction with the tank car companies,
has investigated the causes of all significant loss of
lading incidents and, as a result of these investiga-
tions, suggested to regulatory bodies major improvements
to tank car head shields, insulation and top and bottom
shelf couplers (here, reference may be made to the
testimony of Dr. Harris at the 1981 Show Cause Hearing
given at Hull, Quebec on April 27. 1981, Volume 5. pages
608 to 622). Such advice is given with a view to
improving safety and protecting and enhancing interna-
tional trade. It is respectfully submitted that the RTC
would be ill-advised to ignore the advice, and the
contribution, of a body of experts of this nature.
It is respectfully submitted that, in the present case,
the AAR can be relied upon to assist Canadian railways to
coordinate with the RTC in eliminating the problem that
has obviously provoked concerns. The RTC has undertaken
the investigation necessary to determine the cause of the
Incident MacMillan Yard and, further, has taken immediate
steps to ensure that there are no other cars with a
similar defect operating on Canadian Railways. Thus, In
our submission, the RTC has acted quickly to eliminate
the problem without adverse effects in the realm of
international trade between Canada and its much larger
partner, the United States.
Clearly, however, the RTC is in no position to ignore the
long-term objective of ensuring that cars produced in the
future will not have a similar- defect, but, it is our
submission, that this objective is best pursued
simultaneously in both Canada and the United States.
Only then can the RTC be assured that the long-term
objective of this Inquiry (ensuring that no more cars
with a similar latent defect appear on our Railways) is
achieved without intolerable consequences for interna-
tional competitive position of Canadian shippers and
railways. Again, reference may be made to the decision
of the RTC panel sitting on the 1981 "Show Cause
"In imposing safety prograiranes on the
Railways under its jurisdiction, the
Committee must therefore have regard to
their probable cost and their effect on the
competitive position of the Railways vis a
vis other modes of transportation. This
APPENDIX G -80-
national transportation policy also
prescribes as objectives protection of the
interests of the users of transportation
and the maintenance of the economic well-
being of Canada. It declares that an
economic, efficient and adequate
transportation system making the best use
of all available modes of transportation at
the lowest total cost is essential in
meeting these objectives. These statutory
objectives also point out the requirement
to ensure that interchange of commodities,
development of industry and export trade
are not unduly obstructed (at pages 11 and
In summary, though Canadian Railways must be regulated by
the proper Canadian authority, it is essential to recall
that such regulation cannot take place in a vacuum; it
occurs in an international context, and in some cases,
the regulator must carefully weigh the consequences his
actions will have on international trade. In the present
case, independent Canadian action could have severed
economic consequences while coordination with other
bodies concerned with North American railway traffic
would avoid such consequences."
Procor Limited, in final argument, favoured me with their views on
the comments and opinion expressed by Mr. Justice Grange. Procor stated:
"What he had in mind was not ignoring or duplicating the
present system for tank car design and improval that is
part of the work of the AAR Tank Car Committee; rather,
he suggested that that process be augmented where neces-
sary to adequately respond to Canadian problems. What he
had in mind was that the CTC itself have an independent
"This hearing and the work of the CTC staff clearly
demonstrates the independent position of the CTC at the
present time in dealing with Canadian problems."
Procor was of the view that, in the circumstances of the inquiry,
my reliance upon the Technical Committee was both consistent with the role
Mr. Justice Grange envisioned that public authorities would play and would be
the most appropriate and efficient response to questions raised by the
MacMillan Yard incident.
The Government of Ontario, in final argument, dealt with the com-
ments and opinion of Mr. Justice Grange. The Government pointed out that the
Technical (or Advisory) Committee which had assisted the inquiry had been
unanimous in the view expressed to me in their report:
-81- APPENDIX G
"Recommended that the AAR Tank Car Specifications would
be the best place to introduce all of the above mentioned
recommendations most efficiently. The Tank Car Committee
of AAR should be approached to process those recommenda-
tions. Unanimous verbal agreement individually."
The Government of Ontario believed that "intuitively this must be
so" ~ the AAR was the body that made the rules for the American market and
the American fleet. It was also clear, Ontario argued, that more resources
were available on a continuing basis to AAR than to the Canadian regulatory
authority. The Ontario Government's view, in respect of AAR, was that:
"The difficulty is one of having adequate access to that
"It would be our view that prior to attempting to
replicate American facilities here in Canada that the
Canadian Transport Commission attempt to gain access to
the AAR deliberative process. This does not mean that
the CTC should bind itself unreservedly to American
standards. However, being a part of the deliberative
process would permit the Commission to identify where its
views differ from the American and where it would wish to
depart from the American practice."
That, in the Ontario Government's view, was the point that
Mr. Justice Grange was addressing in his report on Mississauga.
M-Trac's response to the issue posed by Mr. Justice Grange, and on
which I asked for comment, reflected unease with the AAR's handling of the
tank car situation and impatience with the Canadian regulatory authority's
seeming passivity to AAR ascendancy:
"A central question which arises from this inquiry is
whether the Canadian Transport Commission and, through
it, the Railway Transport Committee exercise sufficient
control over the design, manufacture and operation of
pressurized tank cars operating over Canadian track.
In his 1980 report Mr. Justice Grange voiced criticism
over the fact that much of this control rests in American
hands. The car which failed, and cars similar to it,
were designed in the United States, under the direction
and supervision of the rail trade organization, the As-
sociation of American Railroads. Note it is not
Canadian-American, simply American.
This reference is not intended to be unduly critical of
the AAR or its Tank Car Committee. Nevertheless, we are
a sovereign country with technical abilities and
technical goals of our own and it is questionable whether
we need to depend entirely on the American rail
APPENDIX G -82-
technicians to tell us what kind of pressurized tank cars
should run on our tracks."
According to M-Trac, it had been admitted during the inquiry that,
in effect, the CTC had delegated its powers on design and production of
112 tank cars to the AAR. It was true that the Red Book spoke of CTC
approval "but in fact the CTC doesn't exercise much influence over the AAR
and its Tank Car Committee". Yet the inquiry's Technical Committee was cal-
ling now for greater scrutiny of the steel for tank cars and the production
of tank cars.
M-Trac made this point:
"Looking ahead, we can see that chemical traffic is
likely to take an increasing slice of overall rail
traffic. Has the CTC given enough attention to this
prospect? If we are to continue to lean on the AAR to
ensure the production of safe tank cars — keeping the
extremely low Canadian winter temperatures in mind —
must we be resigned to relating our needs and our goals
to those of the American rail industry? Must we
constantly look southward for direction of our
requirements? Surely, it is time for an assessment of
our Canadian technical abilities and our needs."
Canadian Pacific Limited did not, in fipal argument, deal with the
Issue that I had raised through the medium of Mr. Justice Grange's observa-
tions on Canadian public input in respect of AAR's work.
The views expressed by the parties who responded have been of great
assistance to me. They have illuminated an issue that beyond doubt — so far
as I am concerned — must be wrenched from the wings, brought to centre stage
and conclusively dealt with. It is an issue that challenges the professional
capacity of the Canadian Transport Commission as a safety regulator of
railways. What is required now is the administrative action that must be
presumed to have been delayed by other matters seemingly more urgent. The
submissions before me confirm that the issue remains as clearly elucidated in
the Grange Royal Commission Report of 1980.
What is not needed is an initiative by the Canadian Transport Com-
mission seeded with nationalistic bias. (There is nothing of that in the
comments and opinions expressed by Mr. Justice Grange.) We are not looking
at new arrangements -- perhaps they should be called additional arrangements
— that will undermine, in any way, activities of the AAR or interfere with
the Canadian railways' commendable participation in, and contribution to,
this important trade association of North American railways.
What must be sought is a way of injecting meaningfully into the
picture — in addition to "private and American efforts" of undoubted benefit
to Canadian railways and users of their services — the Canadian public
interest . In directing the Commission as to its regulatory mandate.
Parliament, in its several statutes, has repetitively used the words "the
-83- APPENDIX G
public interest" — we are to uphold it. Surely, at the Canadian Transport
Commission, there must come before all else the safety of Canadian citizens
— including employees of the railways — amid all of our heterogeneous
regulatory responsibilities in respect of the rail mode.
I had the impression, particularly reading the argument of CN, that
there is a rather important apple cart here — AAR and the Canadian railways'
participation in it ~ and for heaven's sakes. Commissioner Magee, don't
upset that apple cartl But I do not seek to do so. Why would I? No party
to this inquiry counselled that I should pursue the matter with that negative
objective. Strangely enough, in deciding what I should say to the Commis-
sioners, I think I can walk a path that, in the main, meets the views of all
of the parties (and still be resolute! ). I will try.
A careful analysis of every view expressed by the parties reveals
an emphasis on particular aspects of concern, mainly as to the depth of
involvement and the extent of 'independent action', arising from any newly-
installed capacity of the Canadian Transport Commission to respond to AAR
dicta. There seems to be no cleavage between the parties on the essential
principle — that being that the Commission's Railway Transport Committee
ought to know what is going on. If Mr. Justice Grange, who analyzed the
CTC's safety mandate in his Mississauga Royal Commission Report correctly,
concluded that "the jurisdiction of the Commission and its committee in the
government supervision and investigation of the railways is almost limitless"
then — surely — the Commission i^ supposed to know.
The advice which CN has given me in argument is correct, in my
view, inasmuch as it addresses the importance of the Association of American
Railroads and its essential coordinating role, both as regards interchange of
freight cars and rendering Canadian and United States railway operations safe
and compatible. I agree that the Canadian Transport Commission should be
open on any occasion to "the advice, and the contribution of a body of
experts of this nature" (AAR).
I do not agree that on an occasion when the necessity is
imperative the Canadian Transport Commission should refrain, or even shrink,
from "independent Canadian action".
I would expect that if satisfactory arrangements were in place as
between the Commission and the Association seldom if ever would the necessity
for independent action arise. When people with common goals — trade
associations of the transportation industry and regulatory agencies of
government, the latter with their public input ~ reason together about
urgent safety problems it seems to me they are unlikely to disagree. I was
occupied for 20 years in the first role and have been occupied in the second
for the past 17 years. From that experience, I speak with conviction about
establishing a meaningful and formalized communicative role between CTC and
APPENDIX G -84-
I would rather have seen the Canadian railways try to bring this
aboutl Perhaps — in the way they look at it — they have. But, despite the
goodwill that is evident, does it really advance us very far along the path
to read in CN's argument, in reference to the Technical Committee's report:
"Further, Canadian National Railway Company undertakes to
provide the RTC with regular reports on the handling of
these recommendations by the AAR."
As one of the Members of RTC, this is not for a moment an offer I
would disdain. But is it the complete answer to a kind of relationship that
enables us to say that we — the Canadian Transport Commission — have ar-
rangements in place that meet fundamental requirements of the Canadian public
Procor has told me in argument that these fundamental requirements
of the Canadian public interest — what might be called the Grange format (as
to which Procor itself expresses no disagreement whatever) — have been met
in the practices and methodology followed in the inquiry, particularly the
establishment and work of the inquiry's Technical Committee. I would, of
course, be pleased to think that that is so. However, one must not lose
sight of the fact that what was in effect in this instance was an ad hoc ar-
rangement designed for problems confronting one particular public inquiry.
If the Canadian Government is serious about the Canadian Transport
Commission's railway safety mandate — and I have every reason to believe
that it is — what must be put in place in Canada are not merely ad hoc
arrangements in reference to the Canadian regulatory authority and AAR. What
must be in place in Canada is formal, friendly but firm communication between
the Canadian regulatory authority and AAR as to what, in Washington, D.C.,
the Association there is approving for movement over 57,000 miles of railway
track in Canada. There must be a settled, formal arrangement, with the
funding and qualified staff required in Canada.
Nothing less will give Canadians a 'handle' on what is decided by
the Association in Washington, D.C., as to standards and specifications of
the various types of tank cars traversing railways, in Canada.
In cross-examination, Mr. Stanley Kaplan, Director, Dangerous Com-
modities, gave his view of how much further we need to go:
"Q.: Is the CTC part of the Tank Car Committee?
A: No, neither is the CTC part of the CSA and neither is
DOT part of ASME.
What is extremely necessary, I might just say this,
and this is a personal opinion, is that the government
and the ruling body follows somehow what the Associa-
tion is doing. I don't see the reason for government
to report a work which is owned by somebody else
-85- APPENDIX G
What is important is just to be able to live with it,
in that we follow up the development in the Associa-
tion and that you will satisfy yourself that the work
has gone on in the right way.
Q,: So you would not recommend that the government be
involved in the AAR Tank Car Committee?
A.: No. I would not go that far.
What I would say is that the government should keep
track of what the Tank Car Committee is doing and what
the developments are and participate with them when-
ever there is developments, participating, maybe, on
the technical side, and that I believe will be the
I am sensitive to the fact that, in time of restraint, the
expansion of staff, rather than the diminution of it, is not popular,
although the government, since it took power, has made special provision for
the health and safety of citizens. No problem of the kind I am addressing
has ever struck me as glorious potential for empire building. Twenty prior
years in the private sector has made that reticence ingrained. The fact that
our total safety-related staff ~ all aspects of rail safety, covering the
whole of Canada ~ numbers 152 is evidence of the care that has been shown in
approaching the matter of staffing for safety.
So, too, in our equipment research and testing, whether before or
after a railway accident: we have a contract with the Energy, Mines and
Resources Ministry's excellent Physical Metallurgical Research Laboratories
to do that kind of work for us rather than attempt to replicate such
capability in the CTC. We have, too, a good working relationship with the
National Research Council.
Some new staff, but no large infusion of staff, will, in my view,
give us, at last, a capability to observe, study and respond meaningfully to
the work of AAR in terms of the Canadian public interest:
"...it is not in my opinion enough to rely on private and
"We are concerned with the transportation of dangerous
goods in Canada."
"We must take advantage of all knowledge to be obtained
from any source..."
"...we must also attack the problems from the viewpoint
of the Canadian public..."
"...I am sure there is in Canada knowledge and talent
available to help."
APPENDIX G -86
It was recognized by Mr. Justice Grange that an AAR standard may,
on the average, be acceptable to the Tank Car Committee members who prepared
it. It may be acceptable to their respective 'constituencies' but these may
or may not always include Canadian interests and concerns. It followed that
Mr. Justice Grange felt that there was need for a review and evaluation
mechanism that would function in Canada and, in respect of which, problems
would be looked at from the viewpoint of the Canadian public. The
performance of the ad hoc Technical Committee that served the RTC well in
this inquiry bears out absolutely his surety that "there is in Canada
knowledge and talent available to help".
A means of reviewing and evaluating AAR standards on behalf of the
Canadian public should be created as a specialized advisory group under the
aegis of the Commission's Railway Transport Committee. It must not be
insular -- confined to RTC alone -- but should be structured, if possible, to
tap knowledge and talent available to help, both inside and outside the
Government of Canada and its agencies.
The organizational unit that is proposed should develop and
maintain close relations with the AAR Tank Car Committee and there should
emerge from this a two-way flow of information on activities and conclusions.
An invitation to attend any meeting of the AAR Tank Car Committee at which
our findings or technical expertise are sought by the Committee should be
accepted forthwith — in terms of public safety it is undeniably one of the
most important bodies on the North American continent.
As well, the RTC organizational unit should maintain equally close
ties with the Canadian railways, the tank car manufacturers, dangerous com-
modity tank car users, public bodies concerned with rail safety, research
organizations, standards associations ~ all who have interests in dangerous
corranodity tank car design and specifications. The object here should be
adequate and comprehensive Canadian input to the proposed unit.
The overall objective is to utilize all developments of the AAR in
the context of Canadian evaluation of standards and design specifications of
tank cars running on Canadian railway tracks. If shortcomings or omissions
are found there must be Canadian action to 'fill the gap', always in inter-
action with the interests who have direct concern.
Review and evaluation capacity in terms of tank car standards
should be housed in the Railway Transport Committee, Regionally and at Head-
quarters, in a readily identifiable organizational unit. It must not be
obscured. Its expert staff should be armed with a clearly defined mandate,
known and understood outside the Canadian Transport Commission. Contact
points should be "up front". The communication policy should be one of ready
access to all concerned within CTC — and it is emphasized, in another
section, that this communication ought to be outgoing as well.
The work of this expert group should be so structured and directed
that every category of dangerous commodity tank car in Canada — presumed
healthy or suspect, either having been involved in, or believed to have
precipated, an accident — is a known quantity to the Railway Transport Com-
-87- APPENDIX G
mittee and a candidate for its action when deemed appropriate. All types of
these cars, as they have passed through the AAR Tank Car Committee, will in,
due course, have been reported upon to the RTC. When considered safe they
should be formally approved in that regard. When it appears that a car type
presumed healthy with no past record is now beginning to exhibit an inherent
flaw this would be reported immediately to the RTC by the AAR and dealt with
as circumstances require on both sides of the border.
"Action when deemed appropriate", as the need is perceived by RTC,
should involve communication with the AAR and owners and operators of the
equipment, together with such follow-up action as may be severally possible,
but, failing that, by RTC unilateral action.
The RTC group should conduct its reviews and evaluations on a
priority basis. Dangerous commodity tank cars should come first — foremost
among them, and of No. 1 priority, those carrying CTC-rated "Special
Dangerous Commodities" — the most dangerous of dangerous commodities listed
in the Red Book. Later, as time permits, the other tank cars can be examined
on a descending scale of priority, determined by the relative dangers of the
lading regularly carried in each of these types of car.
During the preparation of this report there were, within RTC, two
waves of special inspections of tank cars. The group whose formation I
suggest should not only avail itself of any inspection reports, whether a
product of regular or special inspections, but should be authorized to set in
motion inspections associated with review of any tank car category. Such
inspections should be carried out either by our Regional or Headquarters
staff, as deemed appropriate in the circumstances.
The new structure in place in the Committee should continue our
policy of making full use of available expertise and facilities within the
Government of Canada — some already referred to in this report — thereby
avoiding duplication of publicly-financed resources. The specialized RTC
staff should, of course, avail itself as well of available resources in the
Research Branch of the Commission. (Research has made, in addition to RTC's
staff, a contribution of consistency and excellence in respect of our
Even if the times and circumstances were opportune, I would not
recommend the luxury of duplication of technical research facilities of AAR.
In order to eradicate the void to which Mr. Justice Grange drew attention,
this is not necessary in my view and I agree also that that precise course of
action is not what Mr. Justice Grange intended. What is required is that the
new group should be staffed by experts of the 'senior' variety and that they
should have the qualifications and capacity to select, and make best use of,
specialists, both inside and outside the Commission — specialists in the
technical and economic and risk evaluation fields, drawn from agencies of
government and from private industry as well. This, by definition, requires
an assigned budget to buy the diverse expertise required.
What I am confronting here is the health and safety of Canadian
citizens in the face of an ever-increasing flow of dangerous commodity
APPENDIX G -88-
traffic on the railways of Canada. The budget of the RTC group in liaison
with AAR should, therefore, be inviolate. It should be administered by the
unit itself, subject only to the appropriate checks, in terms of propriety,
by the designated officers and agencies of the government.
Already stated is my belief that some new staff, but no large
Infusion of staff at this stage, would give us, at long last, a capability to
observe, to study, and to respond meaningfully to, the important work of AAR.
In part, that belief is based on the modest staffing —numerically ~ that I
see as necessary. But that is only part of the foundation upon which my
It must not be forgotten — indeed we +iave been reminded of it in
the arguments of the parties — that the tank inquiry was assisted from the
outset by an ad hoc Technical Coiranittee that consisted of technical and
expert persons drawn from the Railway Transport Committee: CN and CP Rail;
the Association of American Railroads; M-Trac (having nominated
Professor Weatherly from the University of Toronto); Procor Limited; Energy,
Mines and Resources; and the Bureau of Explosives (AAR). This team worked
efficiently and effectively in drawing conclusions, and in reaching
concensus, on a very difficult and complex technical problem — the cause of
failure of UTLX 98646 and action proposed in respect thereof. Having regard
for the somewhat adversarial atmosphere in which such hearings often start
off, I was astonished and pleased by the Technical Committee's achievement.
What we saw in action here, and as a major contribution to uncover-
ing the mysteries of UTLX 98646, was a multi-interest group ~ one of proven
viability in respect of deliberations that, at some future time, will again
be required of RTC.
It is my impression that most, perhaps all, of the parties to the
hearing would support the continued participation of its officers or assigned
experts to a committee of this kind. This was primarily because of the
perceived potential to reduce time and money spent to resolve the cause and
implications of an incident. But my strong view is that there could well be
another benefit — that of review and evaluation of existing and new AAR
standards in terms of their applicability in Canada. As was the case at my
inquiry conducted on behalf of RTC, the Technical Committee in this role
would not be the arbiter but would report to RTC.
It is well worth following up this development — to see if there
is here a useful, long-term mechanism, capable of interaction with the expert
staff of the proposed new unit, the object being to enable RTC to get a more
meaningful grasp on tank car standards and design specifications.
What will the proposed additional capacity of review and evaluation
by the Railway Transport Committee achieve?
It will better protect the safety of the Canadian public by
substituting a formal structure for ad hoc response in Canadian surveillance
and regulation of design and specifications standards originating with the
Association of American Railroads.
-89- APPENDIX G
When that is done, it will better protect the safety of Canadians.
It win butress significantly the credibility of the Railway Transport Com-
mittee at accident investigative hearings. Commissioners will be relieved of
an experience that I, for one, have found demeaning — that of stolidly
receiving evidence about a failed dangerous commodity tank car, with design
and specifications standards approved by the AAR in Washington, D.C., but
having been subject to no meaningful review and approval in Canada for opera-
tions on railway lines passing through thousands of Canadian coirenunities.
As one looks at Sections 227, 228 and 296(1) of the Railway Act ~
to cite examples in the statutes — more is required of us than that.
Subject to the availability of the supplemental staff unit
required, hopefully with the contemplated interaction of the ad hoc Technical
Committee, I recommend to the Railway Transport Committee that it:
(1) Review and evaluate existing and new AAR design and
specifications standards for tank cars designated
for dangerous commodity service to ensure adequacy
in the context of the Canadian environment and
(2) Develop proposed changes (additions, deletions, mod-
ifications) to the aforesaid AAR standards, if
necessary, to ensure adequacy in the context of the
Canadian environment and circumstances, making use
of all available Canadian talent and facilities,
including consideration of risk reduction and the
economic and trade implications of such changes.
(3) Evaluate risk reduction, cost and other implications
of implementation associated with the proposed
(4) Prepare recommendations to the RTC for implementing
those proposed changes which appear worthwhile from
a technical and cost-benefit point of view.
(5) Ensure compliance with the aforesaid standards
through monitoring, inspection and enforcement
(6) Administer a specific budget and staff to facilitate
(7) Prepare reports and advisory memoranda to the RTC
Commissioners pertaining to the mandated duties.
APPENDIX G -go-
es) Maintain close liaison and observer status with the
AAR Tank Car Committee, and close liaison with
Canadian railways, tank car manufacturers and
dangerous commodity tank car owners and users,
public organizations and other interested parties.
(9) Develop an ongoing relationship with an advisory
technical committee consisting of representatives
from such bodies as CN,. CP, the tank car industry,
M-Trac, NRC and EMR (that committee to consist of no
more than ten members).
(10) Conduct liaison, as necessary, with interested
public and governmental bodies and otherwise ensure
public knowledge of the Committee's activities and
The changes set out so as to strengthen our administration of the
law ~ and to give us a formal budgeted structure that will end a partial
void north of the 49^^^ parallel in regard to overseeing and approval of tank
car standards — could come to pass in another way than through this report:
simply, on authority of the Committee's Chief Executive Officer, by taking
the necessary steps to obtain approval of person-years and budget to enable
us to exercise fully our regulatory powers. Other improvements in the past
that were not quasi-judicial ~ requiring no formal Order or Decision ~ have
been handled in that manner.
My feeling, in respect of the responsibility being addressed here
is that the views and conclusions of the whole Committee — all of its Com-
missioner-Members ~ will be constructive and helpful and, affirmatively,
will add authority in moving towards our objective. In this way, the matter
will be understood not merely as one of additional staffing but as a further
initiative of the Railway Transport Committee pursuant to the safety laws
that Parliament directs us to administer.
lU. 5. GOVERNWENT PRINTING OrFICE : 1987-201 -61 : 60019
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